To crack down on price gouging, proposed legislation in Missouri calls for allowing felony charges against health care staffing agencies that substantially raise their prices during a declared emergency.

A New York bill includes a cap on the amount staffing agencies can charge health care facilities. And a Texas measure would allow civil penalties against such agencies.

These proposed regulations — and others in at least 11 more states, according to the American Staffing Association industry trade group — come after demand for travel nurses, who work temporary assignments at different facilities, surged to unprecedented levels during the worst of the covid-19 pandemic.

Hospitals have long used temporary workers, who are often employed by third-party agencies, to help fill their staffing needs. But by December 2021, the average weekly travel nurse pay in the country had soared to $3,782, up from $1,896 in January 2020, according to a Becker’s Hospital Review analysis of data from hiring platform Vivian Health. That platform alone listed over 645,000 active travel nurse jobs in the final three months of 2022.

Some traveling intensive care unit nurses commanded $10,000 a week during the worst of the pandemic, prompting burned-out nurses across the country to leave their hospital staff jobs for more lucrative temporary assignments. Desperate hospitals that could afford it offered signing bonuses as high as $40,000 for nurses willing to make multiyear commitments to join their staff instead.

The escalating costs led hospitals and their allies around the country to rally against what they saw as price gouging by staffing agencies. In February 2021, the American Hospital Association urged the Federal Trade Commission to investigate “anticompetitive pricing” by agencies, and, a year later, hundreds of lawmakers urged the White House to do the same.

No substantial federal action has occurred, so states are trying to take the next step. But the resulting regulatory patchwork could pose a different challenge to hospitals in states with rate caps or other restrictive measures, according to Hannah Neprash, a University of Minnesota health care economics professor. Such facilities could find it difficult to hire travel nurses or could face a lower-quality hiring pool during a national crisis than those in neighboring states without such measures, she said.

For example, Massachusetts and Minnesota already had rate caps for temporary nurses before the pandemic but raised and even waived their caps for some staffing agencies during the crisis.

And any new restrictions may meet stiff resistance, as proposed rate caps did in Missouri last year.

As the covid omicron variant wave began to subside, Missouri legislators considered a proposal that would have set the maximum rate staffing agencies could charge at 150% of the average wage rate of the prior three years plus necessary taxes.

The Missouri Hospital Association, a trade group that represents 140 hospitals across the state, supported the bill as a crackdown on underhanded staffing firms, not on nurses being able to command higher wages, spokesperson Dave Dillon said.

“During the pandemic there were staffing companies who were making a lot of promises and not necessarily delivering,” Dillon said. “It created an opportunity for both profiteering and for bad actors to be able to play in that space.”

Nurses, though, decried what they called government overreach and argued the bill could make the state’s existing nursing shortage worse.

Theresa Newbanks, a nurse practitioner, asked legislators to imagine the government attempting to dictate how much a lawyer, electrician, or plumber could make in Missouri. “This would never be allowed,” she testified to the committee considering the bill. “Yet, this is exactly what is happening, right now, to nurses.”

Another of the nearly 30 people who testified against the bill was Michelle Hall, a longtime nurse and hospital nursing leader who started her own staffing agency in 2021, in part, she said, because she was tired of seeing her peers leave the industry over concerns about unsafe staffing ratios and low pay.

“I felt like I had to defend my nurses,” Hall later told KHN. Her nurses usually receive about 80% of the amount she charges, she said.

Typically about 75% of the price charged by a staffing agency to a health care facility goes to costs such as salary, payroll taxes, workers’ compensation programs, unemployment insurance, recruiting, training, certification, and credential verification, said Toby Malara, a vice president at the American Staffing Association trade group.

He said hospital executives have, “without understanding how a staffing firm works,” wrongly assumed price gouging has been occurring. In fact, he said many of his trade group’s members reported decreased profits during the pandemic because of the high compensation nurses were able to command.

While Missouri lawmakers did not pass the rate cap, they did make changes to the regulations governing staffing agencies, including requiring them to report the average amounts charged per health care worker for each personnel category and the average amount paid to those workers. Those reports will not be public, although the state will use them to prepare its own aggregate reports that don’t identify individual agencies. The public comment period on the proposed regulations was scheduled to begin March 15.

Hall was not concerned about the reporting requirements but said another of the changes might prompt her to close shop or move her business out of state: Agencies will be barred from collecting compensation when their employees get recruited to work for the facility where they temp.

“It doesn’t matter all the money that I have put out prior, to onboard and train that person,” Hall said.

Dillon called that complaint “pretty rich,” noting that agencies routinely recruit hospital staff members by offering higher pay. “Considering the premium agencies charge for staff, I find it hard to believe that this risk isn’t built into their business model,” he said.

Of course, as the pandemic has waned, the demand for travel nursing has subsided. But pay has yet to drop back to pre-pandemic levels. Average weekly travel nurse pay was $3,077 in January, down 20% year over year but still 62% higher in January 2020, according to reporting on Vivian Health data by Becker’s.

With the acute challenges of the pandemic behind hospitals, Dillon said, health system leaders are eyeing proactive solutions to meet their ongoing workforce challenges, such as raising pay and investing in the nursing workforce pipeline.

A hospital in South Carolina, for example, is offering day care for staffers’ children to help retain them. California lawmakers are considering a $25-per-hour minimum wage for health care workers. And some hospitals have even created their own staffing agencies to reduce their reliance on third-party agencies.

But the momentum to directly address high travel nurse rates hasn’t gone away, as evidenced by the legislative push in Missouri this year.

The latest proposal would apply to certain agencies if a “gross disparity” exists between the prices they charge during an emergency and what they charged prior to it or what other agencies are currently charging for similar services and if their earnings are at least 15% higher than before the emergency.

Malara said he doesn’t have much of a problem with this year’s bill because it gives agencies the ability to defend their practices and pricing.

Kentucky last year applied its existing price gouging rules to health care staffing agencies. The rules, which set criteria for acceptable prices, allow increases driven by higher labor costs. Malara said if the Missouri bill gains momentum he will point its sponsor to that language and ask her to clarify what constitutes a “gross disparity” in prices.

The sponsor of the bill, Missouri state Sen. Karla Eslinger, a Republican, did not respond to requests for comment on the legislation.

Hall said she is opposed to any rate caps but is ambivalent about Missouri’s new proposal. She said she saw agencies raising their prices from $70 an hour to over $300 while she worked as a hospital nursing leader at the height of the pandemic.

“All these agencies that were price gouging,” Hall said, “all they were doing was putting that money in their own pockets. They weren’t doing anything different or special for their nurses.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Jessica Layman calcula que ha llamado a más de 150 médicos en los últimos años, buscando a alguno que le recetara opioides para su dolor crónico.

“Muchos directamente insultan”, dijo la mujer de 40 años, que vive en Dallas. “Dicen cosas como ‘no tratamos drogadictos'”.

Layman ha probado una serie de tratamientos no opioides para que la ayuden con el intenso dolor diario que le causa su escoliosis doble, un disco vertebral colapsado, y su artritis articular facetaria. Pero dijo que nada funcionaba tan bien como la metadona, un opioide que ha tomado desde 2013.

Dijo que las últimas llamadas telefónicas fueron a fines del año pasado, después que su médico anterior cerrara su práctica de medicina del dolor. Espera que su actual médico no haga lo mismo. “No tendría adónde ir”, agregó.

Layman es una de las millones de personas en los Estados Unidos que viven con dolor crónico. Muchos han tenido problemas para obtener recetas de opioides, y surtirlas, desde que las pautas de 2016 de los Centros para el Control y la Prevención de Enfermedades (CDC) inspiraron leyes que toman medidas enérgicas contra las prácticas médicas y farmacéuticas.

Los CDC actualizaron recientemente esas recomendaciones para tratar de aliviar su impacto, pero médicos, pacientes, investigadores y defensores dicen que el daño ya está hecho.

“Teníamos un problema masivo con los opioides que debía rectificarse”, dijo Antonio Ciaccia, presidente de 3 Axis Advisors, una firma consultora que analiza los precios de los medicamentos recetados. “Pero las medidas enérgicas y las pautas federales han creado daños colaterales: los pacientes sin recursos”.

Nacido de un esfuerzo por combatir la crisis nacional de sobredosis, la guía condujo a restricciones legales sobre la capacidad de los médicos para recetar analgésicos.

Las recomendaciones dejaron a muchos pacientes lidiando con las consecuencias para la salud mental y física de la reducción rápida de la dosis o la suspensión abrupta de los medicamentos que habían estado tomando durante años, lo que conlleva riesgos de abstinencia, depresión, ansiedad e incluso suicidio.

En noviembre, la agencia publicó nuevas guías, alentando a los médicos a concentrarse en las necesidades individuales de los pacientes. Si bien las pautas aún dicen que los opioides no deberían ser la opción preferida para el dolor, facilitan las recomendaciones sobre los límites de las dosis, que eran estrictos en la guía de los CDC de 2016. Los nuevos estándares también advierten a los médicos sobre los riesgos asociados con los cambios rápidos de dosis después del consumo prolongado.

Pero a algunos médicos les preocupa que las nuevas recomendaciones tarden mucho en lograr un cambio significativo, y pueden ser pocas o llegar tarde para algunos pacientes. Las razones incluyen la falta de coordinación de otras agencias federales, el miedo a las consecuencias legales entre los proveedores, los legisladores estatales que dudan en modificar las leyes y el estigma generalizado que rodea a los medicamentos opioides.

Las pautas de 2016 para recetar opioides a personas con dolor crónico llenaron un vacío para los funcionarios estatales que buscaban soluciones a la crisis de las sobredosis, dijo la doctora Pooja Lagisetty, profesora asistente de medicina en la Facultad de Medicina de la Universidad de Michigan.

Lagisetty dijo que las docenas de leyes que aprobaron los estados que limitan la forma en que los proveedores recetan o dispensan esos medicamentos tuvieron un efecto: una disminución en las recetas de opioides incluso cuando las sobredosis continuaron aumentando.

Las primeras pautas de los CDC “alertaron a todos”, dijo el doctor Bobby Mukkamala, presidente del Grupo de Trabajo de Atención del Dolor y Uso de Sustancias de la Asociación Médica Estadounidense. Los médicos redujeron la cantidad de píldoras de opioides que recetan después de las cirugías, dijo. Las revisiones de 2022 son “un cambio dramático”, dijo.

Es difícil exagerar el costo humano de la crisis de los opioides. Las muertes por sobredosis de opioides han aumentado de manera constante en los Estados Unidos en las últimas dos décadas, con un pico al principio de la pandemia de covid-19. Los CDC dicen que el fentanilo ilícito ha alimentado un aumento reciente en las muertes por sobredosis.

Teniendo en cuenta la perspectiva de los pacientes con dolor crónico, las recomendaciones más recientes intentan reducir algunos de los daños a las personas que se habían beneficiado de los opioides pero a los que se les cortó el suministro, dijo la doctora Jeanmarie Perrone, directora del Penn Medicine Center for Addiction Medicine and Policy.

“Espero que sigamos difundiendo la precaución sin propagar demasiado el temor de nunca usar opioides”, dijo Perrone, quien ayudó a elaborar las últimas recomendaciones de los CDC.

Christopher Jones, director del Centro Nacional para la Prevención y el Control de Lesiones de los CDC, dijo que las recomendaciones actualizadas no son un mandato regulatorio sino solo una herramienta para ayudar a los médicos a “tomar decisiones informadas y centradas en la persona relacionadas con el tratamiento del dolor”.

Múltiples estudios cuestionan si los opioides son la forma más efectiva de tratar el dolor crónico a largo plazo. Pero la reducción gradual de las drogas se asocia con muertes por sobredosis y suicidio, y el riesgo aumenta cuanto más tiempo una persona ha estado tomando opioides, según una investigación del doctor Stefan Kertesz, profesor de medicina en la Universidad de Alabama-Birmingham.

Dijo que la nueva guía de los CDC refleja “una cantidad extraordinaria de aportes” de los pacientes con dolor crónico y sus médicos, pero duda que tenga un gran impacto si la Administración de Drogas y Alimentos (FDA) y la Administración de Control de Drogas (DEA) no cambian la forma en que hacen cumplir las leyes federales.

La FDA aprueba nuevos medicamentos y sus reformulaciones, pero la orientación que brinda sobre cómo comenzar o removerle la droga a los pacientes podría instar a los médicos a hacerlo con precaución, dijo Kertesz. La DEA, que investiga a los médicos sospechosos de recetar ilegalmente opioides, se negó a comentar.

La búsqueda de médicos por parte de la DEA puso a Danny Elliott, de Warner Robins, Georgia, en una situación horrible, dijo su hermano, Jim.

En 1991, Danny, representante de una empresa farmacéutica, sufrió una descarga eléctrica. Tomó medicamentos para el dolor por la lesión cerebral resultante durante años hasta que su médico enfrentó cargos federales por dispensar ilegalmente opioides recetados, contó Jim.

Danny recurrió a médicos fuera del estado, primero en Texas y luego en California. Pero la DEA suspendió la licencia de su último médico el año pasado y no pudo encontrar un nuevo médico que le recetara esos medicamentos, dijo Jim.

Danny, de 61 años, y su esposa, Gretchen, de 59, se suicidaron en noviembre. “Estoy realmente frustrado y enojado porque los pacientes con dolor son maltratados”, dijo Jim.

Poco antes de morir, Danny se convirtió en un defensor contra la reducción forzada de drogas. Los pacientes con dolor crónico que hablaron con KHN señalaron su difícil situación al pedir más acceso a medicamentos opioides.

Incluso para las personas que tienen receta, no siempre es fácil obtener los medicamentos que necesitan.

Las cadenas de farmacias y los mayoristas de medicamentos han resuelto demandas por miles de millones de dólares por su supuesto papel en la crisis de los opioides. Algunas farmacias han visto limitadas o cortadas sus asignaciones de opioides, señaló Ciaccia, de 3 Axis Advisors.

Rheba Smith, de 61 años, de Atlanta, dijo que en diciembre su farmacia dejó de surtir sus recetas de Percocet y MS Contin. Había tomado esos medicamentos opioides durante años para controlar el dolor crónico después de que le cortaran el nervio ilíaco por error durante una cirugía, contó.

Smith dijo que visitó casi dos docenas de farmacias a principios de enero, pero no pudo encontrar una que pudiera surtir sus recetas. Finalmente encontró una farmacia local de pedidos por correo que le surtió un suministro de Percocet para un mes. Pero ahora ese medicamento y MS Contin no están disponibles, le dijeron en la farmacia.

“Han sido tres meses horribles. He tenido un dolor terrible”, dijo Smith.

Muchos pacientes temen un futuro de dolor constante. Layman piensa en todo lo que haría para conseguir medicamentos.

“¿Estarías dispuesto a comprar drogas en la calle? ¿A ir a una clínica de adicciones y tratar de recibir tratamiento para el dolor allí? ¿Qué estás dispuesto a hacer para seguir con vida? dijo. “A eso se reduce todo”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Jessica Layman estimates she has called more than 150 doctors in the past few years in her search for someone to prescribe opioids for her chronic pain.

“A lot of them are straight-up insulting,” said the 40-year-old, who lives in Dallas. “They say things like ‘We don’t treat drug addicts.’”

Layman has tried a host of non-opioid treatments to help with the intense daily pain caused by double scoliosis, a collapsed spinal disc, and facet joint arthritis. But she said nothing worked as well as methadone, an opioid she has taken since 2013.

The latest phone calls came late last year, after her previous doctor shuttered his pain medicine practice, she said. She hopes her current doctor won’t do the same. “If something should happen to him, there’s nowhere for me to go,” she said.

Layman is one of the millions in the U.S. living with chronic pain. Many have struggled to get opioid prescriptions written and filled since 2016 guidelines from the Centers for Disease Control and Prevention inspired laws cracking down on doctor and pharmacy practices. The CDC recently updated those recommendations to try to ease their impact, but doctors, patients, researchers, and advocates say the damage is done.

“We had a massive opioid problem that needed to be rectified,” said Antonio Ciaccia, president of 3 Axis Advisors, a consulting firm that analyzes prescription drug pricing. “But the federal crackdowns and guidelines have created collateral damage: patients left high and dry.”

Born of an effort to fight the nation’s overdose crisis, the guidance led to legal restrictions on doctors’ ability to prescribe painkillers. The recommendations left many patients grappling with the mental and physical health consequences of rapid dose tapering or abruptly stopping medication they’d been taking for years, which carries risks of withdrawal, depression, anxiety, and even suicide.

In November, the agency released new guidelines, encouraging physicians to focus on the individual needs of patients. While the guidelines still say opioids should not be the go-to option for pain, they ease recommendations about dose limits, which were widely viewed as hard rules in the CDC’s 2016 guidance. The new standards also warn doctors about risks associated with rapid dose changes after long-term use.

But some doctors worry the new recommendations will take a long time to make a meaningful change — and may be too little, too late for some patients. The reasons include a lack of coordination from other federal agencies, fear of legal consequences among providers, state policymakers hesitant to tweak laws, and widespread stigma surrounding opioid medication.

The 2016 guidelines for prescribing opioids to people with chronic pain filled a vacuum for state officials searching for solutions to the overdose crisis, said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.

The dozens of laws that states passed limiting how providers prescribe or dispense those medications, she said, had an effect: a decline in opioid prescriptions even as overdoses continued to climb.

The first CDC guidelines “put everybody on notice,’’ said Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force. Physicians reduced the number of opioid pills they prescribe after surgeries, he said. The 2022 revisions are “a dramatic change,” he said.

The human toll of the opioid crisis is hard to overstate. Opioid overdose deaths have risen steadily in the U.S. in the past two decades, with a spike early in the covid-19 pandemic. The CDC says illicit fentanyl has fueled a recent surge in overdose deaths.

Taking into account the perspective of chronic pain patients, the latest recommendations try to scale back some of the harms to people who had benefited from opioids but were cut off, said Dr. Jeanmarie Perrone, director of the Penn Medicine Center for Addiction Medicine and Policy.

“I hope we just continue to spread caution without spreading too much fear about never using opioids,” said Perrone, who helped craft the CDC’s latest recommendations.

Christopher Jones, director of the CDC’s National Center for Injury Prevention and Control, said the updated recommendations are not a regulatory mandate but only a tool to help doctors “make informed, person-centered decisions related to pain care.”

Multiple studies question whether opioids are the most effective way to treat chronic pain in the long term. But drug tapering is associated with deaths from overdose and suicide, with risk increasing the longer a person had been taking opioids, according to research by Dr. Stefan Kertesz, a professor of medicine at the University of Alabama-Birmingham.

He said the new CDC guidance reflects “an extraordinary amount of input” from chronic pain patients and their doctors but doubts it will have much of an impact if the FDA and the Drug Enforcement Administration don’t change how they enforce federal laws.

The FDA approves new drugs and their reformulations, but the guidance it provides for how to start or wean patients could urge clinicians to do so with caution, Kertesz said. The DEA, which investigates physicians suspected of illegally prescribing opioids, declined to comment.

The DEA’s pursuit of doctors put Danny Elliott of Warner Robins, Georgia, in a horrible predicament, said his brother, Jim.

In 1991, Danny, a pharmaceutical company rep, suffered an electric shock. He took pain medicine for the resulting brain injury for years until his doctor faced federal charges of illegally dispensing prescription opioids, Jim said.

Danny turned to doctors out of state — first in Texas and then in California. But Danny’s latest physician had his license suspended by the DEA last year, and he couldn’t find a new doctor who would prescribe those medications, Jim said.

Danny, 61, and his wife, Gretchen, 59, died by suicide in November. “I’m really frustrated and angry about pain patients being cut off,” Jim said.

Danny became an advocate against forced drug tapering before he died. Chronic pain patients who spoke with KHN pointed to his plight in calling for more access to opioid medications.

Even for people with prescriptions, it’s not always easy to get the drugs they need.

Pharmacy chains and drug wholesalers have settled lawsuits for billions of dollars over their alleged role in the opioid crisis. Some pharmacies have seen their opioid allocations limited or cut off, noted Ciaccia, with 3 Axis Advisors.

Rheba Smith, 61, of Atlanta, said that in December her pharmacy stopped filling her prescriptions for Percocet and MS Contin. She had taken those opioid medications for years to manage chronic pain after her iliac nerve was mistakenly cut during surgery, she said.

Smith said she visited nearly two dozen pharmacies in early January but could not find one that would fill her prescriptions. She finally found a local mail-order pharmacy that filled a one-month supply of Percocet. But now that drug and MS Contin are not available, the pharmacy told her.

“It has been a horrible three months. I have been in terrible pain,” Smith said.

Many patients fear a future of constant pain. Layman thinks about the lengths she’d go to in order to get medication.

“Would you be willing to buy drugs off the street? Would you be willing to go to an addiction clinic and try to get pain treatment there? What are you willing to do to stay alive?” she said. “That is what it comes down to.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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