Last winter, Amber Wingler started getting a series of increasingly urgent messages from the local hospital in Columbia, Missouri, letting her know her family’s health care might soon be upended.

MU Health Care, where most of her family’s doctors work, was mired in a contract dispute with Wingler’s health insurer, Anthem. The existing contract was set to expire.

Then, on March 31, Wingler received an email alerting her that the next day Anthem was dropping the hospital from its network. It left her reeling.

“I know that they go through contract negotiations all the time … but it just seemed like bureaucracy that wasn’t going to affect us. I’d never been pushed out-of-network like that before,” she said.  

The timing was awful.

The query: When a Missouri mom’s health insurance company couldn’t come to an agreement with her hospital, most of her doctors were suddenly out-of-network. She wondered how she would get her kids’ care covered or find new doctors. “For a family of five, … where do we even start?”

— Amber Wingler, 42, in Columbia, Missouri

Wingler’s 8-year-old daughter, Cora, had been having unexplained troubles with her gut. Waitlists to see various pediatric specialists to get a diagnosis, from gastroenterology to occupational therapy, were long — ranging from weeks to more than a year.

(In a statement, MU Health Care spokesperson Eric Maze said the health system works to make sure children with the most urgent needs are seen as quickly as possible.)

Suddenly, the specialist visits for Cora were out-of-network. At a few hundred bucks a piece, the out-of-pocket cost would have added up fast. The only other in-network pediatric specialists Wingler found were in St. Louis and Kansas City, both more than 120 miles away.

So Wingler delayed her daughter’s appointments for months while she tried to figure out what to do.

Nationwide, contract disputes are common, with more than 650 hospitals having public spats with an insurer since 2021. They could become even more common as hospitals brace for about $1 trillion in cuts to federal health care spending prescribed by President Donald Trump’s signature legislation signed into law in July.

Patients caught in a contract dispute have few good options. “There’s that old African proverb: that when two elephants fight, the grass gets trampled. And unfortunately, in these situations, oftentimes patients are grass,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps people who are having trouble accessing health care.

If you’re feeling trampled by a contract dispute between a hospital and your insurer, here is what you need to know to protect yourself financially:

1. “Out-of-network” means you’ll likely pay more.

Insurance companies negotiate contracts with hospitals and other medical providers to set the rates they will pay for various services. When they reach an agreement, the hospital and most of the providers who work there become part of the insurance company’s network.

Most patients prefer to see providers who are “in-network” because their insurance picks up some, most, or even all of the bill, which could be hundreds or thousands of dollars. If you see an out-of-network provider, you could be on the hook for the whole tab.

If you decide to stick with your familiar doctors even though they’re out-of-network, consider asking about getting a cash discount and about the hospital’s financial assistance program.

2. Rifts between hospitals and insurers often get repaired.

When Brown University health policy researcher Jason Buxbaum examined 3,714 nonfederal hospitals across the U.S., he said, he found that about 18% of them had a public dispute with an insurance company sometime from June 2021 to May 2025.

About half of those hospitals ultimately dropped out of the insurance company’s network, according to Buxbaum’s preliminary data. But most of those breakups ultimately get resolved within a month or two, he added. So your doctors very well could end up back in the network, even after a split.

3. You might qualify for an exception to keep costs lower.

Certain patients with serious or complex conditions might qualify for an extension of in-network coverage, called continuity of care. You can apply for that extension by contacting your insurer, but the process may prove lengthy. Some hospitals have set up resources to help patients apply for that extension.

Wingler ran that gantlet for her daughter, spending hours on the phone, filling out forms, and sending faxes. But she said she didn’t have the time or energy to do that for everyone in her family.

“My son was going through physical therapy,” she said. “But I’m sorry, dude, like, just do your exercises that you already have. I’m not fighting to get you coverage too, when I’m already fighting for your sister.”

Also worth noting, if you’re dealing with a medical emergency: For most emergency services, hospitals can’t charge patients more than their in-network rates.

4. Switching your insurance carrier may need to wait.

You might be thinking of switching to an insurer that covers your preferred doctors. But be aware: Many people who choose their insurance plans during an annual open enrollment period are locked into their plan for a year. Insurance contracts with hospitals are not necessarily on the same timeline as your “plan year.”

Certain life events, such as getting married, having a baby, or losing a job, can qualify you to change insurance outside of your annual open enrollment period, but your doctors’ dropping out of an insurance network is not a qualifying life event.

5. Doctor-shopping can be time-consuming.

If the split between your insurance company and hospital looks permanent, you might consider finding a new slate of doctors and other providers who are in-network with your plan. Where to start? Your insurance plan likely has an online tool to search for in-network providers near you. 

But know that making a switch could mean waiting to establish yourself as a patient with a new doctor and, in some cases, traveling a fair distance.

6. It’s worth holding on to your receipts.

Even if your insurance and hospital don’t strike a deal before their contract expires, there’s a decent chance they will still make a new agreement.

Some patients decide to put off appointments while they wait. Others keep their appointments and pay out-of-pocket. Hold on to your receipts if you do. When insurers and hospitals make up, the deals often are backdated, so the appointments you paid for out-of-pocket could be covered after all.

End of an Ordeal

Three months after the contract between Wingler’s insurance company and the hospital lapsed, the sides announced they had reached a new agreement. Wingler joined the throng of patients scheduling appointments they’d delayed during the ordeal.

In a statement, Jim Turner, a spokesperson for Anthem’s parent company, Elevance Health, wrote, “We approach negotiations with a focus on fairness, transparency, and respect for everyone impacted.”

Maze from MU Health Care said: “We understand how important timely access to pediatric specialty care is for families, and we’re truly sorry for the frustration some parents have experienced scheduling appointments following the resolution of our Anthem contract negotiations.”

Wingler was happy her family could see their providers again, but her relief was tempered by a resolve not to be caught in the same position again.

“I think we will be a little more studious when open enrollment comes around,” Wingler said. “We’d never really bothered to look at our out-of-pocket coverage before because we didn’t need it.”

Author: Bram Sable-Smith: brams@kff.org, @besables

Illustrations: Oona Zenda: ozenda@kff.org

The post So Your Insurance Dropped Your Doctor. Now What? appeared first on Medika Life.

On Fridays, Stephanie Johnson has a busy schedule, driving her navy-blue Jeep from one patient’s home to the next, seeing eight in all. Pregnant with her second child, she schleps a backpack instead of a traditional black bag to carry a laptop and essential medical supplies — stethoscope, blood pressure cuff, and pulse oximeter.

This story also ran on The Washington Post.

Forget a lunch break; she often eats a sandwich or some nuts as she heads to her next patient visit.

On a gloomy Friday in January, Johnson, a nurse practitioner who treats older adults, had a hospice consult with Ellen, a patient in her 90s in declining health. To protect Ellen’s identity, KFF Health News is not using her last name.

“Hello. How are you feeling?” Johnson asked as she entered Ellen’s bedroom and inquired about her pain. The blinds were drawn. Ellen was in a wheelchair, wearing a white sweater, gray sweatpants, and fuzzy socks. A headband was tied around her white hair. As usual, the TV was playing loudly in the background.

“It’s fine, except this cough I’ve had since junior high,” Ellen said.

Ellen had been diagnosed with vascular dementia, peripheral vascular disease, and Type 2 diabetes. Last fall, doctors made the difficult decision to operate on her foot. Before the surgery, Ellen was always colorful, wearing purple, yellow, blue, pink, and chunky necklaces. She enjoyed talking with the half dozen other residents at her adult family home in Washington state. She had a hearty appetite that brought her to the breakfast table early. But lately, her enthusiasm for meals and socializing had waned.

Johnson got down to eye level with Ellen to examine her, assessing her joints and range of motion, checking her blood pressure, and listening to her heart and lungs.

Carefully, Johnson removed the bandage to examine Ellen’s toes. Her lower legs were red but cold to the touch, which indicated her condition wasn’t improving. Ellen’s two younger sisters had power of attorney for her and made it clear that, above all, they wanted her to be comfortable. Now, Johnson thought it was time to have that difficult conversation with them about Ellen’s prognosis, recommending her for hospice.

“Our patient isn’t just the older adult,” Johnson said. “It’s also often the family member or the person helping to manage them.”

Nurse practitioners are having those conversations more and more as their patient base trends older. They are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines. The Health Resources and Services Administration projects a 50% increase in demand for geriatricians from 2018 to 2030, when the entire baby boom generation will be older than 65. By then, hundreds of geriatricians are expected to retire or leave the specialty, reducing their number to fewer than 7,600, with relatively few young doctors joining the field.

That means many older adults will be relying on other primary care physicians, who already can’t keep up with demand, and nurse practitioners, whose ranks are booming. The number of nurse practitioners specializing in geriatrics has more than tripled since 2010, increasing the availability of care to the current population of seniors, a recent study in JAMA Network Open found.

According to a 2024 survey, of the roughly 431,000 licensed nurse practitioners, 15% are, like Johnson, certified to treat older adults.

Johnson and her husband, Dustin, operate an NP-led private practice in greater Seattle, Washington, a state where she can practice independently. She and her team, which includes five additional nurse practitioners, each try to see about 10 patients a day, visiting each one every five to six weeks. Visits typically last 30 minutes to an hour, depending on the case.

“There are so many housebound older adults, and we’re barely reaching them,” Johnson said. “For those still in their private homes, there’s such a huge need.”

Laura Wagner, a professor of nursing and community health systems at the University of California-San Francisco, stressed that nurse practitioners are not trying to replace doctors; they’re trying to meet patients’ needs, wherever they may be.

“One of the things I’m most proud of is the role of nurse practitioners,” she said. “We step into places where other providers may not, and geriatrics is a prime example of that.”

Practice Limits

Nurse practitioners are registered nurses with advanced training that enables them to diagnose diseases, analyze diagnostic tests, and prescribe medicine. Their growth has bolstered primary care, and, like doctors, they can specialize in particular branches of medicine. Johnson, for example, has advanced training in gerontology.

“If we have a geriatrician shortage, then hiring more nurse practitioners trained in geriatrics is an ideal solution,” Wagner said, “but there are a lot of barriers in place.”

In 27 states and Washington, D.C., nurse practitioners can practice independently. But in the rest of the country, they need to have a collaborative agreement with or be under the supervision of another health care provider to provide care to older adults. Medicare generally reimburses for nurse practitioner services at 85% of the amount it pays physicians.

Last year, in more than 40 states, the American Medical Association and its partners lobbied against what they see as “scope creep” in the expanded roles of nurse practitioners and other health workers. The AMA points out that doctors must have more schooling and significantly more clinical experience than nurse practitioners. While the AMA says physician-led teams keep costs lower, a study published in 2020 in Health Services Research found similar patient outcomes and lower costs for nurse practitioner patients. Other studies, including one published in 2023 in the journal Medical Care Research and Review, have found health care models including nurse practitioners had better outcomes for patients with multiple chronic conditions than teams without an NP.

Five states have granted NPs full practice authority since 2021, with Utah the most recent state to remove physician supervision requirements, in 2023. In March, however, Mississippi House Bill 849, which would have increased NP independence, failed. Meanwhile, 30 Texas physicians rallied to tamp down full-scope efforts in Austin.

“I would fully disagree that we’re invading their scope of practice and shouldn’t have full scope of our own,” Johnson said.

She has worked under the supervision of physicians in Pennsylvania and Washington state but started seeing patients at her own practice in 2021. Like many nurse practitioners, she sees her patients in their homes. The first thing she does when she gets a new patient is manage their prescriptions, getting rid of unnecessary medications, especially those with harsh side effects.

She works with the patient and a family member who often has power of attorney. She keeps them informed of subtle changes, such as whether a person was verbal and eating and whether their medical conditions have changed.

While there is some overlap in expertise between geriatricians and nurse practitioners, there are areas where nurses typically excel, said Elizabeth White, an assistant professor of health services, policy, and practice at Brown University.

“We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs. That’s very much in the nursing domain,” she said.

That care coordination will become even more critical as the U.S. ages. Today, about 18% of the U.S. population is 65 or over. In the next 30 years, the share of seniors is expected to reach 23%, as medical and technological advances enable people to live longer.

Patient and Family

In an office next to Ellen’s bedroom, Johnson called Ellen’s younger sister Margaret Watt to recommend that Ellen enter hospice care. Johnson told her that Ellen had developed pneumonia and her body wasn’t coping.

Watt appreciated that Johnson had kept the family apprised of Ellen’s condition for several years, saying she was a good communicator.

“She was accurate,” Watt said. “What she said would happen, happened.”

A month after the consult, Ellen died peacefully in her sleep.

“I do feel sadness,” Johnson said, “but there’s also a sense of relief that I’ve been with her through her suffering to try to alleviate it, and I’ve helped her meet her and her family’s priorities in that time.”

Jariel Arvin is a reporter with the Investigative Reporting Program at the University of California-Berkeley Graduate School of Journalism. He reported this article through a grant from The SCAN Foundation.

The post Nurse Practitioners Critical in Treating Older Adults as Ranks of Geriatricians Shrink appeared first on Medika Life.

TUSTIN, Calif. — Cynthia Williams is furious with U.S. House Republicans willing to slash Medicaid, the government-run insurance program for people with low incomes or disabilities.

The 61-year-old Anaheim resident cares for her adult daughter, who is blind, and for her sister, a military veteran with severe post-traumatic stress disorder and other mental health conditions. Medi-Cal, the state’s version of Medicaid, pays Williams to care for them, and she relies on that income, just as her sister and daughter depend on her.

“Let’s be real. We shouldn’t have to be here tonight,” Williams told a raucous standing-room crowd of over 200 people at a recent town hall. “We should be home, spending time with our loved ones and our families, but we’re here. And we’re here to fight, because when politicians try to take away our health care, we don’t have the option to sit back and let it happen.”

The House last week approved a Republican budget plan that could shrink Medicaid spending by $880 billion over 10 years, only partially paying for an extension of expiring tax cuts from President Donald Trump’s first term, plus some new ones he has promised, totaling as much as $4.5 trillion.

A spending cut of that magnitude would have a huge impact in California, with nearly 15 million people — more than a third of the population — on Medi-Cal. Over 60% of Medi-Cal’s $161 billion budget comes from Washington.

Williams was among about a dozen providers, patient advocates, disabled people, and family members who stood up one after the other to tell their stories. Rep. Young Kim, a Republican whose district includes this relatively affluent Orange County city, declined an invitation for her or a staff member to attend. But her constituents delivered their message loud and clear to her and the other Republicans in Congress: Hands off Medicaid.

Josephine Rios, a certified nursing assistant at a Kaiser Permanente surgical center in Irvine, said her 7-year-old grandson, Elijah, has received indispensable treatments through Medi-Cal, including a $5,000-a-month medication that controls his seizures, which can be life-threatening. Elijah, who has cerebral palsy, is among the more than 50% of California children covered by Medi-Cal.

“To cut Medicaid, Medi-Cal, that’s like saying he can’t live. He can’t thrive. He’s going to lie in bed and do nothing,” Rios said. “Who are they to judge who lives and who doesn’t?”

Two thirds of Californians across party lines oppose cuts to Medi-Cal, according to a new survey by the California Health Care Foundation and NORC at the University of Chicago.

The town hall here was one of three organized late last month by “Fight for Our Health,” a coalition of health advocacy groups and unions, to target Republican House members whose California districts are considered politically competitive. The other two were in Bakersfield, part of which is represented by Rep. David Valadao, and Corona, home to Rep. Ken Calvert. Multiple other town halls and protests have sprung up across the country in recent weeks.

The coalition has reprised a campaign — part of a broader national movement — that fought against the GOP’s unsuccessful 2017 effort to repeal the Affordable Care Act.

The Republicans’ loss of House control in the 2018 midterm elections has been widely attributed to their stance on health care. Valadao was among the GOP members who lost their seats in 2018, though he took his back two years later.

Still, he voted for the House budget proposal last week, despite the fact that about two-thirds of the population in his district is on Medicaid — the highest in the state — and even though he is one of eight GOP House members who sent a letter to Speaker Mike Johnson warning about the “serious consequences” of deep cuts to Medicaid. Valadao’s office did not respond to requests for comment.

Calvert, who’s been in the House for 32 years and eked out reelection last November, also voted for the budget, as did Kim. All nine GOP members of California’s congressional delegation supported it, as did all House Republicans except one.

Critics of the budget plan say it helps the rich at the expense of society’s most vulnerable — an argument that was vigorously repeated at the Tustin town hall. But supporters of the plan say that extending the tax cuts, key provisions of which are set to expire at the end of this year, would avoid a large tax hike for average Americans and benefit low-income families the most.

“American families are facing a massive tax increase unless Congress acts by the end of the year,” Calvert said in a statement to KFF Health News before the vote. He vowed the GOP would not touch Social Security or Medicare. He did not offer similar assurances on Medicaid, but said, “We are not interested in cutting the social and healthcare safety net for children, disabled, and low-income Americans. We are focused on eliminating waste, fraud, and abuse.”

The document greenlit last Tuesday does not specify spending cut details, though it instructs the Energy and Commerce Committee, which oversees Medicaid and Medicare spending, to cut $880 billion — a large chunk of the up to $2 trillion in total cuts. The GOP’s razor-thin majority means Johnson will have a narrow path to get a more detailed budget passed. Republican support, whether from fiscal hawks who want deeper spending cuts or House members worried about slashing Medicaid, could ebb and flow as the details are hashed out.

Moreover, the House must reach a compromise with the Senate, which has passed a much narrower budget resolution that leaves the big tax cuts out for now.

Like Kim, Valadao and Calvert declined invitations to attend or send staffers to the town hall meetings in their regions. At the Tustin meeting, multiple speakers chided Kim for her absence. At one point, the large screen behind the podium flashed a picture of an empty chair with the words, in large block letters, “Congresswoman Kim, we saved you a seat.”

Kim spokesperson Callie Strock said in an email that Kim and her local staff had preexisting commitments that night. She added that Kim is “committed to protecting and strengthening our health care system.”

But those in attendance were clearly worried.

“It’s a moral obligation for all of us to look at the most disadvantaged people in our country and take good care of them,” said Beth Martinko, whose 33-year-old son, Josh, has autism and relies on Medi-Cal for his care. “This has no place in politics.”

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

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

The post To Patients, Parents, and Caregivers, Proposed Medicaid Cuts Are a Personal Affront appeared first on Medika Life.

Erica Hayes, 40, has not felt healthy since November 2020 when she first fell ill with covid.

Hayes is too sick to work, so she has spent much of the last four years sitting on her beige couch, often curled up under an electric blanket.

“My blood flow now sucks, so my hands and my feet are freezing. Even if I’m sweating, my toes are cold,” said Hayes, who lives in Western Pennsylvania. She misses feeling well enough to play with her 9-year-old son or attend her 17-year-old son’s baseball games.

Along with claiming the lives of 1.2 million Americans, the covid-19 pandemic has been described as a mass disabling event. Hayes is one of millions of Americans who suffer from long covid. Depending on the patient, the condition can rob someone of energy, scramble the autonomic nervous system, or fog their memory, among many other symptoms.

In addition to the brain fog and chronic fatigue, Hayes’ constellation of symptoms includes frequent hives and migraines. Also, her tongue is constantly swollen and dry.

“I’ve had multiple doctors look at it and tell me they don’t know what’s going on,” Hayes said about her tongue. 

Estimates of prevalence range considerably, depending on how researchers define long covid in a given study, but the Centers for Disease Control and Prevention puts it at 17 million adults.

Despite long covid’s vast reach, the federal government’s investment in researching the disease — to the tune of $1.15 billion as of December — has so far failed to bring any new treatments to market. 

This disappoints and angers the patient community, who say the National Institutes of Health should focus on ways to stop their suffering instead of simply trying to understand why they’re suffering.

“It’s unconscionable that more than four years since this began, we still don’t have one FDA-approved drug,” said Meighan Stone, executive director of the Long COVID Campaign, a patient-led advocacy organization. Stone was among several people with long covid who spoke at a workshop hosted by the NIH in September where patients, clinicians, and researchers discussed their priorities and frustrations around the agency’s approach to long-covid research.

Some doctors and researchers are also critical of the agency’s research initiative, called RECOVER, or Researching COVID to Enhance Recovery. Without clinical trials, physicians specializing in treating long covid must rely on hunches to guide their clinical decisions, said Ziyad Al-Aly, chief of research and development with the VA St Louis Healthcare System.

“What [RECOVER] lacks, really, is clarity of vision and clarity of purpose,” said Al-Aly, saying he agrees that the NIH has had enough time and money to produce more meaningful progress.

Now the NIH is starting to determine how to allocate an additional $662 million of funding for long-covid research, $300 million of which is earmarked for clinical trials. These funds will be allocated over the next four years.

At the end of October, RECOVER issued a request for clinical trial ideas that look at potential therapies, including medications, saying its goal is “to work rapidly, collaboratively, and transparently to advance treatments for Long COVID.”

This turn suggests the NIH has begun to respond to patients. This has stirred cautious optimism among those who say that the agency’s approach to long covid has lacked urgency in the search for effective treatments.

Stone calls this $300 million a down payment. She warns it’s going to take a lot more money to help people like Hayes regain some degree of health.

“There really is a burden to make up this lost time now,” Stone said.

The NIH told KFF Health News and NPR via email that it recognizes the urgency in finding treatments. But to do that, there needs to be an understanding of the biological mechanisms that are making people sick, which is difficult to do with post-infectious conditions.

That’s why it has funded research into how long covid affects lung function, or trying to understand why only some people are afflicted with the condition.

Good Science Takes Time

In December 2020, Congress appropriated $1.15 billion for the NIH to launch RECOVER, raising hopes in the long-covid patient community.

Then-NIH Director Francis Collins explained that RECOVER’s goal was to better understand long covid as a disease and that clinical trials of potential treatments would come later.

According to RECOVER’s website, it has funded eight clinical trials to test the safety and effectiveness of an experimental treatment or intervention. Just one of those trials has published results.

On the other hand, RECOVER has supported more than 200 observational studies, such as research on how long covid affects pulmonary function and on which symptoms are most common. And the initiative has funded more than 40 pathobiology studies, which focus on the basic cellular and molecular mechanisms of long covid.

RECOVER’s website says this research has led to crucial insights on the risk factors for developing long covid and on understanding how the disease interacts with preexisting conditions.

It notes that observational studies are important in helping scientists to design and launch evidence-based clinical trials.

Good science takes time, said Leora Horwitz, the co-principal investigator for the RECOVER-Adult Observational Cohort at New York University. And long covid is an “exceedingly complicated” illness that appears to affect nearly every organ system, she said. 

This makes it more difficult to study than many other diseases. Because long covid harms the body in so many ways, with widely variable symptoms, it’s harder to identify precise targets for treatment.

“I also will remind you that we’re only three, four years into this pandemic for most people,” Horwitz said. “We’ve been spending much more money than this, yearly, for 30, 40 years on other conditions.”

NYU received nearly $470 million of RECOVER funds in 2021, which the institution is using to spearhead the collection of data and biospecimens from up to 40,000 patients. Horwitz said nearly 30,000 are enrolled so far.

This vast repository, Horwitz said, supports ongoing observational research, allowing scientists to understand what is happening biologically to people who don’t recover after an initial infection — and that will help determine which clinical trials for treatments are worth undertaking.

“Simply trying treatments because they are available without any evidence about whether or why they may be effective reduces the likelihood of successful trials and may put patients at risk of harm,” she said.

Delayed Hopes or Incremental Progress?

The NIH told KFF Health News and NPR that patients and caregivers have been central to RECOVER from the beginning, “playing critical roles in designing studies and clinical trials, responding to surveys, serving on governance and publication groups, and guiding the initiative.”

But the consensus from patient advocacy groups is that RECOVER should have done more to prioritize clinical trials from the outset. Patients also say RECOVER leadership ignored their priorities and experiences when determining which studies to fund.

RECOVER has scored some gains, said JD Davids, co-director of Long COVID Justice. This includes findings on differences in long covid between adults and kids.

But Davids said the NIH shouldn’t have named the initiative “RECOVER,” since it wasn’t designed as a streamlined effort to develop treatments.

“The name’s a little cruel and misleading,” he said.

RECOVER’s initial allocation of $1.15 billion probably wasn’t enough to develop a new medication to treat long covid, said Ezekiel J. Emanuel, co-director of the University of Pennsylvania’s Healthcare Transformation Institute.

But, he said,  the results of preliminary clinical trials could have spurred pharmaceutical companies to fund more studies on drug development and test how existing drugs influence a patient’s immune response.

Emanuel is one of the authors of a March 2022 covid roadmap report. He notes that RECOVER’s lack of focus on new treatments was a problem. “Only 15% of the budget is for clinical studies. That is a failure in itself — a failure of having the right priorities,” he told KFF Health News and NPR via email.

And though the NYU biobank has been impactful, Emanuel said there needs to be more focus on how existing drugs influence immune response.

He said some clinical trials that RECOVER has funded are “ridiculous,” because they’ve focused on symptom amelioration, for example to study the benefits of over-the-counter medication to improve sleep. Other studies looked at non-pharmacological interventions, such as exercise and “brain training” to help with cognitive fog.

People with long covid say this type of clinical research contributes to what many describe as the “gaslighting” they experience from doctors, who sometimes blame a patient’s symptoms on anxiety or depression, rather than acknowledging long covid as a real illness with a physiological basis.

“I’m just disgusted,” said long-covid patient Hayes. “You wouldn’t tell somebody with diabetes to breathe through it.”

Chimére L. Sweeney, director and founder of the Black Long Covid Experience, said she’s even taken breaks from seeking treatment after getting fed up with being told that her symptoms were due to her diet or mental health.

“You’re at the whim of somebody who may not even understand the spectrum of long covid,” Sweeney said.

Insurance Battles Over Experimental Treatments

Since there are still no long-covid treatments approved by the Food and Drug Administration, anything a physician prescribes is classified as either experimental — for unproven treatments — or an off-label use of a drug approved for other conditions. This means patients can struggle to get insurance to cover prescriptions.

Michael Brode, medical director for UT Health Austin’s Post-COVID-19 Program — said he writes many appeal letters. And some people pay for their own treatment.

For example, intravenous immunoglobulin therapy, low-dose naltrexone, and hyperbaric oxygen therapy are all promising treatments, he said.

For hyperbaric oxygen, two small, randomized controlled studies show improvements for the chronic fatigue and brain fog that often plague long-covid patients. The theory is that higher oxygen concentration and increased air pressure can help heal tissues that were damaged during a covid infection.

However, the out-of-pocket cost for a series of sessions in a hyperbaric chamber can run as much as $8,000, Brode said.

“Am I going to look a patient in the eye and say, ‘You need to spend that money for an unproven treatment’?” he said. “I don’t want to hype up a treatment that is still experimental. But I also don’t want to hide it.”

There’s a host of pharmaceuticals that have promising off-label uses for long covid, said microbiologist Amy Proal, president and chief scientific officer at the Massachusetts-based PolyBio Research Foundation. For instance, she’s collaborating on a clinical study that repurposes two HIV drugs to treat long covid.

Proal said research on treatments can move forward based on what’s already understood about the disease. For instance, she said that scientists have evidence — partly due to RECOVER research — that some patients continue to harbor small amounts of viral material after a covid infection. She has not received RECOVER funds but is researching antivirals.

But to vet a range of possible treatments for the millions suffering now — and to develop new drugs specifically targeting long covid — clinical trials are needed. And that requires money.

Hayes said she would definitely volunteer for an experimental drug trial. For now, though, “in order to not be absolutely miserable,” she said she focuses on what she can do, like having dinner with her family.

At the same time, Hayes doesn’t want to spend the rest of her life on a beige couch. 

RECOVER’s deadline to submit research proposals for potential long-covid treatments is Feb. 1.

The post Long-Covid Patients Are Frustrated That Federal Research Hasn’t Found New Treatments appeared first on Medika Life.

“First 100 days,” said Means, a former consultant to Big Pharma who uses the social platform X to focus attention on chronic disease. “What should be done to reform the FDA?”

The question was more than rhetorical. Means is among a cadre of health business leaders and nonmainstream doctors who are influencing President Donald Trump’s focus on health policy.

Trump’s return to the White House has given Means and others in this space significant clout in shaping the nascent health policies of the new administration and its federal agencies. It’s also giving newfound momentum to “Make America Healthy Again,” or MAHA, a controversial movement that challenges prevailing thinking on public health and chronic disease.

Its followers couch their ideals in phrases like “health freedom” and “true health.” Their stated causes are as diverse as revamping certain agricultural subsidies, firing National Institutes of Health employees, rethinking childhood vaccination schedules, and banning marketing of ultra-processed foods to children on TV.

Public health leaders say the emerging Trump administration’s interest in elevating the sometimes unorthodox concepts could be catastrophic, eroding decades of scientific progress while spurring a rise in preventable disease. They worry the administration’s support could weaken trust in public health agencies.

Georges Benjamin, executive director of the American Public Health Association, said he welcomes broad intellectual scientific discussion but is concerned that Trump will parrot untested and unproven public health ideas he hears as if they are fact.

Experience has shown that people with unproven ideas will have his ear and his “very large bully pulpit,” he said. “Because he’s president, people will believe he won’t say things that aren’t true. This president, he will.”

But those in the MAHA camp have a very different take. They say they have been maligned as dangerous for questioning the status quo. The election has given them an enormous opportunity to shape politics and policies, and they say they won’t undermine public health. Instead, they say, they will restore trust in federal health agencies that lost public support during the pandemic.

“It may be a brilliant strategy by the right,” said Peter McCullough, a cardiologist who has come under fire for saying covid-19 vaccines are unsafe. He was describing some of the election-season messaging that mainstreamed their perspectives. “The right was saying we care about medical and environmental issues. The left was pursuing abortion rights and a negative campaign on Trump. But everyone should care about health. Health should be apolitical.”

The movement is largely anti-regulatory and anti-big government, whether concerning raw milk or drug approvals, although implementing changes would require more regulation. Many of its concepts cross over to include ideas that have also been championed by some on the far left.

Robert F. Kennedy Jr., an anti-vaccine activist Trump has nominated to run the Department of Health and Human Services, has called for firing hundreds of people at the National Institutes of Health, removing fluoride from water, boosting federal support for psychedelic therapy, and loosening restrictions on raw milk, consumption of which can expose consumers to foodborne illness. Its sale has prompted federal raids on farms for not complying with food safety regulations.

Means has called for top-down changes at the U.S. Department of Agriculture, which he says has been co-opted by the food industry.

Though he himself is not trained in science or medicine, he has said people had almost no chance of dying of covid-19 if they were “metabolically healthy,” referring to eating, sleeping, exercise, and stress management habits, and has said that about 85% of deaths and health care costs in the U.S. are tied to preventable foodborne metabolic conditions.

A co-founder of Truemed, a company that helps consumers use pretax savings and reimbursement programs on supplements, sleep aids, and exercise equipment, Means says he has had conversations behind closed doors with dozens of members of Congress. He said he also helped bring RFK Jr. and Trump together. RFK Jr. endorsed Trump in August after ending his independent presidential campaign.

“I had this vision for a year, actually. It sounds very woo-woo, but I was in a sweat tent with him in Austin at a campaign event six months before, and I just had this strong vision of him standing with Trump,” Means said recently on the Joe Rogan Experience podcast.

The former self-described never-Trumper said that, after Trump’s first assassination attempt, he felt it was a powerful moment. Means called RFK Jr. and worked with conservative political commentator Tucker Carlson to connect him to the former president. Trump and RFK Jr. then had weeks of conversations about topics such as child obesity and causes of infertility, Means said.

“I really felt, and he felt, like this could be a realignment of American politics,” Means said.

He is joined in the effort by his sister, Casey Means, a Stanford University-trained doctor and co-author with her brother of “Good Energy,” a book about improving metabolic health. The duo has blamed Big Pharma and the agriculture industry for increasing rates of obesity, depression, and chronic health conditions in the country. They have also raised questions about vaccines.

“Yeah, I bet that one vaccine probably isn’t causing autism, but what about the 20 that they are getting before 18 months,” Casey Means said in the Joe Rogan podcast episode with her brother.

The movement, which challenges what its adherents call “the cult of science,” gained significant traction during the pandemic, fueled by a backlash against vaccine and mask mandates that flourished during the Biden administration. Many of its supporters say they gained followers who believed they had been misled on the effectiveness of covid-19 vaccines.

In July 2022, Deborah Birx, covid-19 response coordinator in Trump’s first administration, said on Fox News that “we overplayed the vaccines,” although she noted that they do work.

Anthony Fauci, who advised Trump during the pandemic, in December 2020 called the vaccines a game changer that could diminish covid-19 the way the polio vaccine did for that disease.

Eventually, though, it became evident that the shots don’t necessarily prevent transmission and the effectiveness of the booster wanes with time, which some conservatives say led to disillusionment that has driven interest in the health freedom movement.

Federal health officials say the rollout of the covid vaccine was a turning point in the pandemic and that the shots lessen the severity of the disease by teaching the immune system to recognize and fight the virus that causes it.

Postelection, some Trump allies such as Elon Musk have called for Fauci to be prosecuted. Fauci declined to comment.

Joe Grogan, a former director of the White House’s Domestic Policy Council and assistant to Trump, said conservatives have been trying to articulate why government control of health care is troublesome.

“Two things have happened. The government went totally overboard and lied about many things during covid and showed no compassion about people’s needs outside of covid,” he said. “RFK Jr. came along and articulated very simply that government control of health care can’t be trusted, and we’re spending money, and it isn’t making anyone healthier. In some instances, it may be making people sicker.”

The MAHA movement capitalizes on many of the nonconventional health concepts that have been darlings of the left, such as promoting organic foods and food as medicine. But in an environment of polarized politics, the growing prominence of leaders who challenge what they call the cult of science could lead to more public confusion and division, some health analysts say.

Jeffrey Singer, a surgeon and senior fellow at the Cato Institute, a libertarian public policy research group, said in a statement that he agrees with RFK Jr.’s focus on reevaluating the public health system. But he said it comes with risks.

“I am concerned that many of RFK Jr.’s claims about vaccine safety, environmental toxins, and food additives lack evidence, have stoked public fears, and contributed to a decline in childhood vaccination rates,” he said.

Measles vaccination among kindergartners in the U.S. dropped to 92.7% in the 2023-24 school year from 95.2% in the 2019-20 school year, according to the Centers for Disease Control and Prevention. The agency said that has left about 280,000 kindergartners at risk.

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.

The post Make America Healthy Again: An Unconventional Movement That May Have Found Its Moment appeared first on Medika Life.

I have no idea what the outcome of this very close election will be. I do, however, have a fix on several of the ways health care played a role in the election and in campaign strategy. It won’t change much by election day.

With no big health reform debate to command the attention of the nation and no big health proposal from either candidate, this is not a “health care election,” except, of course, for the impact abortion will have on voting and turnout, whatever the outcome on November 5.

But health care has played a role in the campaign and the election in the following significant ways.

First and foremost, voter concerns about their medical bills are an integral part of their worries about the economy and their costs, mixed in with general inflation and other pocketbook issues such as food, gas prices, and the rent or the mortgage. Most national polls continue to miss this, treating health care as a separate issue. When you treat health care as a stand-alone issue, it ranks as a fairly low priority. However, out-of-pocket health care costs and worries about unexpected medical bills are a big part of the public’s economic worries. Exit polls have made the same mistake. Determining the role health plays on voters’ decisions requires an extra question, which takes time that short polls often do not have. The question that needs to be asked is a variation on this follow-up: “You said the economy was your number one concern. What about the economy most worries you?” The question can be open ended, or respondents can be given a list to choose from. There are arguments for either approach.

The advantage Vice President Harris and the Democrats have on health has also had an impact on former President Trump and his campaign strategy. He has generally backed off plans to repeal the Affordable Care Act (ACA), saying various things, including recently that he has “concepts of a plan,” but mostly protesting that he now wants to “make the ACA better” with no specifics. He’s also pledged that he will not cut Medicare (no such pledge on Medicaid). And he backtracked on his earlier, more bullish positions on drug costs, going silent on his plan to tie drug costs in the U.S. to what other countries pay, apparently wanting to stay away from even popular health proposals. Overall, he has ceded health care to Harris, likely wary that she will get traction with criticisms that he would take health coverage away from millions and weaken protections for pre-existing conditions.

Harris has taken the opposite approach on the issue that Trump has about an equivalent advantage on—immigration—by taking the offensive to try to close the gap. And she has tried to do the same on the economy with some success, according to several recent polls. (Of course, positions taken in campaigns do not necessarily presage positions a candidate will take if elected.)

The sweeping proposals made by several conservative think tanks to fundamentally change Medicare, Medicaid, and the ACA have been swept under the rug by the Trump campaign, even as Democrats have had some success making Project 2025 a symbol of right-wing extremism. That doesn’t mean the candidate and his administration will not embrace some elements of these plans if elected or appoint some of their architects to high positions. It is, however, a notable element of the campaign, and an acknowledgment that these ideas are a target for Democrats and that Trump and his campaign know that many of them would be controversial and unpopular.

Senator JD Vance’s brief and somewhat vague foray into segmenting healthy and sick people into separate risk pools as an alternative to ACA protections for people with pre-existing conditions was treated by Trump almost the same way he treated the think tank plans: he ignored it. It was as if health had become radioactive for Trump, who campaigned on other issues, including immigration, which he saw as more favorable to him.

Health might have been more of an important issue in the campaign if differences between the candidates and the parties on converting Medicare to a voucher-like, premium support plan, or Medicaid to a block grant to the states, were clarified for voters by the candidates themselves, the debate moderators, or the media generally. Debate moderators focused more on the ACA, likely because of the drama associated with Trump’s earlier attempts to repeal it. Had Trump been forced to choose between embracing or rejecting either of these big and controversial policy proposals, it would have elevated health in the campaign and might have been a flashpoint.

The Democratic left’s concern that Trump might be elected has led them to hold fire on pushing for the more expansive health reform proposals they favor, instead supporting President Biden’s more moderate, incremental policies, and subsequently, the proposals made by Vice President Harris. Should Harris prevail, expect the left to feel less constrained and to hear again about Medicare for All, the public option, Medicare Buy-In, and other policies favored by the left. Passage of legislation on these ideas, or others, is an entirely different matter, especially if Congress is divided.

Harris’s new proposal to add a home care benefit to Medicare may find favor with some elderly and near elderly voters, especially senior women or their family members. That’s one thing to watch as the voters go to the polls. The idea should be popular unless voters come to doubt that Harris can deliver. So far Harris has proposed popular benefits such as extending the $2,000 cap on out-of-pocket drug costs and the $35 monthly cap on Insulin to the private sector, and she has endorsed continuing the enhanced ACA subsidies. She has avoided proposals that would inflame the powerful health care industry, such as extending drug price negotiation to employer coverage.

These are some of the ways in which health care and health care costs have played a role in the presidential campaign. It’s certainly true that health care has not been decisive in this election, but it has played a role, and always will.

View all of Drew’s Beyond the Data Columns

The post The Role Health PLAYED in the Election appeared first on Medika Life.

Usually I worry about amplifying misinformation by calling attention to it. But when it comes to misinformation about immigrants—and most recently Haitian immigrants in Springfield, Ohio—it can’t be elevated much more than it already has been by the Republican candidates for Vice President and President and subsequent media coverage of their remarks. As if acknowledging the role politicians can play magnifying misinformation, vice presidential candidate JD Vance told CNN: “I have to create stories so the media pays attention.” In this case, sharing a few facts won’t elevate the misinformation further and might help dispel myths.

Black immigrants make up only 8% of all adult immigrants. Nearly half (47%) of Black immigrants—or about 4% of immigrants overall—are from the Caribbean, while about four in 10 (43%) are from sub-Saharan Africa. Most Black immigrants are U.S. citizens (68%), while one in five (21%) has a valid visa or green card. Just about one in 10 (8%) are likely undocumented. There are about 700,000 Haitian immigrants in the U.S. and by the way, around 100,000 of them work in the health care sector.

Overwhelmingly, as with all waves of immigrants before them, Black immigrants come to the United States to improve their lives (87%) and their children’s life chances (80%). To accomplish that, most are working (76%). In the case of Haiti, of course, some are fleeing chaos and political instability and have been granted Temporary Protected Status.

They face all the challenges immigrants have always faced in the U.S. Half of Black immigrants (56%) say they face discrimination or unfair treatment at work, but Black immigrants can experience the double trouble of racism and anti-immigrant sentiment.

Politicians have long appealed to Americans who feel alienated or left behind and can be made to feel threatened by newcomers. In what social scientists call “limited empirical validation,” one anecdote or two can be used to validate a stereotype even if it is an outlier. We see that most sharply in the claim, based on a few incidents, that immigrants are widely committing murder.

As a KFF Health Misinformation Tracking Poll released today shows, the strategy is particularly effective with the Republican base. Republicans are much more likely than Democrats and substantially more likely than Independents to believe that immigrants are causing violent crime in the U.S. or that they are taking away jobs.

Most adults (80%) have heard the claim that immigrants cause violence. It’s the ultimate example of amplification of misinformation by political figures based on the intentional use of anecdotes. And it creates a dilemma for news coverage of this and similar examples of misinformation perpetrated by political figures: whether to cover it because it’s news and fact check it in the process, knowing that spreads it much further, including causing further rounds of social media attention; or ignore it knowing that then it will remain mostly in the echo chamber where it began.

There’s likely no choice when presidential candidates spread false information but to cover it and correct the lies in the process, but there are choices to be made about how it’s done. Giving free media to misinformation by broadcasting endless clips of candidates repeating falsehoods and misinformation may do more harm than good, even if they are followed by fact checking. Just ask the Haitians in Springfield, Ohio how they feel about it.

The post Springfield, Ohio: How Candidates Amplify Misinformation appeared first on Medika Life.

The FDA has approved an updated covid shot for everyone 6 months old and up, which renews a now-annual quandary for Americans: Get the shot now, with the latest covid outbreak sweeping the country, or hold it in reserve for the winter wave?

ABOut the partnership

Healthbeat is a newsroom partnership between KFF Health News and Civic News Company that produces reporting on public health and the systems of prevention that communities rely on to stay healthy. 

The new vaccine should provide some protection to everyone. But many healthy people who have already been vaccinated or have immunity because they’ve been exposed to covid enough times may want to wait a few months.

Covid has become commonplace. For some, it’s a minor illness with few symptoms. Others are laid up with fever, cough, and fatigue for days or weeks. A much smaller group — mostly older or chronically ill people — suffer hospitalization or death.

It’s important for those in high-risk groups to get vaccinated, but vaccine protection wanes after a few months. Those who run to get the new vaccine may be more likely to fall ill this winter when the next wave hits, said William Schaffner, an infectious disease professor at Vanderbilt University School of Medicine and a spokesperson for the National Foundation for Infectious Diseases.

On the other hand, by late fall the major variants may have changed, rendering the vaccine less effective, said Peter Marks, the FDA’s top vaccine official, at a briefing Aug. 23. He urged everyone eligible to get immunized, noting that the risk of long covid is greater in the un- and undervaccinated.

Of course, if last year’s covid vaccine rollout is any guide, few Americans will heed his advice, even though this summer’s surge has been unusually intense, with levels of the covid virus in wastewater suggesting infections are as widespread as they were in the winter.

The Centers for Disease Control and Prevention now looks to wastewater as fewer people are reporting test results to health authorities. The wastewater data shows the epidemic is worst in Western and Southern states. In New York, for example, levels are considered “high” — compared with “very high” in Georgia.

Hospitalizations and deaths due to covid have trended up, too. But unlike infections, these rates are nowhere near those seen in winter surges, or in summers past. More than 2,000 people died of covid in July — a high number but a small fraction of the at least 25,700 covid deaths in July 2020.

Partial immunity built up through vaccines and prior infections deserves credit for this relief. A new study suggests that current variants may be less virulent — in the study, one of the recent variants did not kill mice exposed to it, unlike most earlier covid variants.

Public health officials note that even with more cases this summer, people seem to be managing their sickness at home. “We did see a little rise in the number of cases, but it didn’t have a significant impact in terms of hospitalizations and emergency room visits,” said Manisha Juthani, public health commissioner of Connecticut, at a news briefing Aug. 21.

Unlike influenza or traditional cold viruses, covid seems to thrive outside the cold months, when germy schoolkids, dry air, and indoor activities are thought to enable the spread of air- and saliva-borne viruses. No one is exactly sure why.

“Covid is still very transmissible, very new, and people congregate inside in air-conditioned rooms during the summer,” said John Moore, a virologist and professor at Cornell University’s Weill Cornell Medicine.

Or “maybe covid is more tolerant of humidity or other environmental conditions in the summer,” said Caitlin Rivers, an epidemiologist at Johns Hopkins University.

Because viruses evolve as they infect people, the CDC has recommended updated covid vaccines each year. Last fall’s booster was designed to target the omicron variant circulating in 2023. This year, mRNA vaccines made by Moderna and Pfizer and the protein-based vaccine from Novavax — which has yet to be approved by the FDA — target a more recent omicron variant, JN.1.

The FDA determined that the mRNA vaccines strongly protected people from severe disease and death — and would do so even though earlier variants of JN.1 are now being overtaken by others.

Public interest in covid vaccines has waned, with only 1 in 5 adults getting vaccinated since last September, compared with about 80% who got the first dose. New Yorkers have been slightly above the national vaccination rate, while in Georgia only about 17% got the latest shot.

Vaccine uptake is lower in states where the majority voted for Donald Trump in 2020 and among those who have less money and education, less health care access, or less time off from work. These groups are also more likely to be hospitalized or die of the disease, according to a 2023 study in The Lancet.

While the newly formulated vaccines are better targeted at the circulating covid variants, uninsured and underinsured Americans may have to rush if they hope to get one for free. A CDC program that provided boosters to 1.5 million people over the last year ran out of money and is ending Aug. 31.

The agency drummed up $62 million in unspent funds to pay state and local health departments to provide the new shots to those not covered by insurance. But “that may not go very far” if the vaccine costs the agency around $86 a dose, as it did last year, said Kelly Moore, CEO of Immunize.org, which advocates for vaccination.

People who pay out-of-pocket at pharmacies face higher prices: CVS plans to sell the updated vaccine for $201.99, said Amy Thibault, a spokesperson for the company.

“Price can be a barrier, access can be a barrier” to vaccination, said David Scales, an assistant professor of medicine at Weill Cornell Medicine.

Without an access program that provides vaccines to uninsured adults, “we’ll see disparities in health outcomes and disproportionate outbreaks in the working poor, who can ill afford to take off work,” Kelly Moore said.

New York State has about $1 million to fill the gaps when the CDC’s program ends, said Danielle De Souza, a spokesperson for the New York State Department of Health. That will buy around 12,500 doses for uninsured and underinsured adults, she said. There are roughly one million uninsured people in the state.

CDC and FDA experts last year decided to promote annual fall vaccination against covid and influenza along with a one-time respiratory syncytial virus shot for some groups.

It would be impractical for the vaccine-makers to change the covid vaccine’s recipe twice every year, and offering the three vaccines during one or two health care visits appears to be the best way to increase uptake of all of them, said Schaffner, who consults for the CDC’s policy-setting Advisory Committee on Immunization Practices.

At its next meeting, in October, the committee is likely to urge vulnerable people to get a second dose of the same covid vaccine in the spring, for protection against the next summer wave, he said.

If you’re in a vulnerable population and waiting to get vaccinated until closer to the holiday season, Schaffner said, it makes sense to wear a mask and avoid big crowds, and to get a test if you think you have covid. If positive, people in these groups should seek medical attention since the antiviral pill Paxlovid might ameliorate their symptoms and keep them out of the hospital.

As for conscientious others who feel they may be sick and don’t want to spread the covid virus, the best advice is to get a single test and, if positive, try to isolate for a few days and then wear a mask for several days while avoiding crowded rooms. Repeat testing after a positive result is pointless, since viral particles in the nose may remain for days without signifying a risk of infecting others, Schaffner said.

The Health and Human Services Department is making four free covid tests available to anyone who requests them starting in late September through covidtest.gov, said Dawn O’Connell, assistant secretary for preparedness and response, at the Aug. 23 briefing.

The government is focusing its fall vaccine advocacy campaign — which it’s calling “Risk Less. Do More.” — on older people and nursing home residents, said HHS spokesperson Jeff Nesbit.

Not everyone may really need a fall covid booster, but “it’s not wrong to give people options,” John Moore said. “The 20-year-old athlete is less at risk than the 70-year-old overweight dude. It’s as simple as that.”

******

KFF Health News correspondent Amy Maxmen contributed to this report. Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. This article was updated at 2:40 p.m. ET on Sept. 5, 2024, to correct the name of the Department of Health and Human Services’ fall vaccine advocacy campaign.

The post The New Covid Vaccine Is Out. Why You Might Not Want To Rush To Get It appeared first on Medika Life.

JACKSONVILLE, Fla. — Facing an ultracompetitive market in one of the nation’s fastest-growing cities, UF Health is trying a new way to attract patients: a combination emergency room and urgent care center.

In the past year and a half, UF Health and a private equity-backed company, Intuitive Health, have opened three centers that offer both types of care 24/7 so patients don’t have to decide which facility they need.

Instead, doctors there decide whether it’s urgent or emergency care —the health system bills accordingly — and inform the patient of their decision at the time of the service.

“Most of the time you do not realize where you should go — to an urgent care or an ER — and that triage decision you make can have dramatic economic repercussions,” said Steven Wylie, associate vice president for planning and business development at UF Health Jacksonville. About 70% of patients at its facilities are billed at urgent care rates, Wylie said.

Emergency care is almost always more expensive than urgent care. For patients who might otherwise show up at the ER with an urgent care-level problem — a small cut that requires stitches or an infection treatable with antibiotics — the savings could be hundreds or thousands of dollars.

While no research has been conducted on this new hybrid model, consumer advocates worry hospitals are more likely to route patients to costlier ER-level care whenever possible.

For instance, some services that trigger higher-priced, ER-level care at UF Health’s facilities — such as blood work and ultrasounds — can be obtained at some urgent care centers.

“That sounds crazy, that a blood test can trigger an ER fee, which can cost thousands of dollars,” said Cynthia Fisher, founder and chair of PatientRightsAdvocate.org, a patient advocacy organization.

For UF Health, the hybrid centers can increase profits because they help attract patients. Those patient visits can lead to more revenue through diagnostic testing and referrals for specialists or inpatient care.

Offering less expensive urgent care around-the-clock, the hybrid facilities stand out in an industry known for its aggressive billing practices.

On a recent visit to one of UF Health’s facilities about 15 miles southeast of downtown, several patients said in interviews that they sought a short wait for care. None had sat in the waiting room more than five minutes.

“Sometimes urgent care sends you to the ER, so here you can get everything,” said Andrea Cruz, 24, who was pregnant and came in for shortness of breath. Cruz said she was being treated as an ER patient because she needed blood tests and monitoring.

“It’s good to have a place like this that can treat you no matter what,” said Penny Wilding, 91, who said she has no regular physician and was being evaluated for a likely urinary tract infection.

UF Health is one of about a dozen health systems in 10 states partnering with Intuitive Health to set up and run hybrid ER-urgent care facilities. More are in the works; VHC Health, a large hospital in Arlington, Virginia, plans to start building one this year.

Intuitive Health was established in 2008 by three emergency physicians. For several years the company ran independent combination ER-urgent care centers in Texas.

Then Altamont Capital Partners, a multibillion-dollar private equity firm based in Palo Alto, California, bought a majority stake in Intuitive in 2014.

Soon after, the company began partnering with hospitals to open facilities in states including Arizona, Indiana, Kentucky, and Delaware. Under their agreements, the hospitals handle medical staff and billing while Intuitive manages administrative functions — including initial efforts to collect payment, including checking insurance and taking copays — and nonclinical staff, said Thom Herrmann, CEO of Intuitive Health.

Herrmann said hospitals have become more interested in the concept as Medicare and other insurers pay for value instead of just a fee for each service. That means hospitals have an incentive to find ways to treat patients for less.

And Intuitive has a strong incentive to partner with hospitals, said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University: Facilities licensed as freestanding emergency rooms — as Intuitive’s are — must be affiliated with hospitals to be covered by Medicare.

At the combo facilities, emergency room specialists determine whether to bill for higher-priced ER or lower-priced urgent care after patients undergo a medical screening. They compare the care needed against a list of criteria that trigger emergency-level care and bills, such as the patient requiring IV fluids or cardiac monitoring.

Inside its combo facilities, UF posts a sign listing some of the urgent care services it offers, including treatment for ear infections, sprains, and minor wounds. When its doctors determine ER-level care is necessary, UF requires patients to sign a form acknowledging they will be billed for an ER visit.

Patients who opt out of ER care at that time are charged a triage fee. UF would not disclose the amount of the fee, saying it varies.

UF officials say patients pay only for the level of care they need. Its centers accept most insurance plans, including Medicare, which covers people older than 65 and those with disabilities, and Medicaid, the program for low-income people.

But there are important caveats, said Fisher, the patient advocate.

Patients who pay cash for urgent care at UF’s hybrid centers are charged an “all-inclusive” $250 fee, whether they need an X-ray or a rapid strep test, to name two such services, or both.

But if they use insurance, patients may have higher cost sharing if their health plan is charged more than it would pay for stand-alone urgent care, she said.

Also, federal surprise billing protections that shield patients in an ER don’t extend to urgent care centers, Fisher said.

Herrmann said Intuitive’s facilities charge commercial insurers for urgent care the same as if they provided only urgent care. But Medicare may pay more.

While urgent care has long been intended for minor injuries and illnesses and ERs are supposed to be for life- or health-threatening conditions, the two models have melded in recent years. Urgent care clinics have increased the scope of injuries and conditions they can treat, while hospitals have taken to advertising ER wait times on highway billboards to attract patients.

Intuitive is credited with pioneering hybrid ER-urgent care, though its facilities are not the only ones with both “emergency” and “urgent care” on their signs. Such branding can sometimes confuse patients.

While Intuitive’s hybrid facilities offer some price transparency, providers have the upper hand on cost, said Vivian Ho, a health economist at Rice University in Texas. “Patients are at the mercy of what the hospital tells them,” she said.

But Daniel Marthey, an assistant professor of health policy and management at Texas A&M University, said the facilities can help patients find a lower-cost option for care by avoiding steep ER bills when they need only urgent-level care. “This is a potentially good thing for patients,” he said.

Marthey said hospitals may be investing in hybrid facilities to make up for lost revenue after federal surprise medical billing protections took effect in 2022 and restricted what hospitals could charge patients treated by out-of-network providers, particularly in emergencies.

“Basically, they are just competing for market share,” Marthey said.

UF Health has placed its new facilities in suburban areas near freestanding ERs owned by competitors HCA Healthcare and Ascension rather than near its downtown hospital in Jacksonville. It is also building a fourth facility, near The Villages, a large retirement community more than 100 miles south.

“This has been more of an offensive move to expand our market reach and go into suburban markets,” Wylie said.

Though the three centers are not state-approved to care for trauma patients, doctors there said they can handle almost any emergency, including heart attacks and strokes. Patients needing hospitalization are taken by ambulance to the UF hospital about 20 minutes away. If they need to follow up with a specialist, they’re referred to a UF physician.

“If you fall and sprain your leg and need an X-ray and crutches, you can come here and get charged urgent care,” said Justin Nippert, medical director of two of UF’s combo centers. “But if you break your ankle and need it put back in place it can get treated here, too. It’s a one-stop shop.”

Author: Phil Galewitz: pgalewitz@kff.org, @philgalewitz

The post Urgent Care or ER? With ‘One-Stop Shop,’ Hospitals Offer Both Under Same Roof appeared first on Medika Life.

LOS ANGELES — They distribute GPS devices so they can track their homeless patients. They stock their street kits with glass pipes used to smoke meth, crack, or fentanyl. They keep company credit cards on hand in case a patient needs emergency food or water, or an Uber ride to the doctor.

These doctors, nurses, and social workers are fanning out on the streets of Los Angeles to provide health care and social services to homeless people — foot soldiers of a new business model taking root in communities around California.

Their strategy: Build trust with homeless people to deliver medicine wherever they are — and make money doing it.

“The biggest population of homeless people in this country is here in Southern California,” said Sachin Jain, a former Obama administration health official who is CEO of SCAN Group, which runs a Medicare Advantage insurance plan covering about 300,000 people in California, Arizona, Nevada, Texas, and New Mexico.

“The fastest-growing segment of people experiencing homelessness is actually older adults,” he said. “I said, ‘We’ve got to do something about this.’”

Jain’s organization three years ago created Healthcare in Action, a medical group that sends practitioners onto California’s streets solely to care for homeless people. It has grown rapidly, building operations in 17 communities, including Long Beach, West Hollywood, and San Bernardino County.

Since its launch, Healthcare in Action has cared for about 6,700 homeless patients and managed roughly 77,000 diagnoses, from schizophrenia to diabetes. It has placed about 300 people into permanent or temporary housing.

Street medicine in most of the country is practiced as a charitable endeavor, aimed at serving a challenging patient population failed by traditional medicine, its proponents say. Living transient, chaotic lives, homeless people suffer disproportionately from mental illness, addiction, and chronic disease and often don’t have health insurance — or don’t use it if they do.

That makes designing a business around caring for them a risk, insurance executives and health economists say.

“It’s really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored,” said Mark Duggan, a professor of economics at Stanford University who specializes in homelessness and Medicaid policy. “Financial incentives matter massively in health care. It’s everything.”

An estimated 181,000 people were homeless in California in 2023 — about 30% of the nation’s total. The number living outside, more than two-thirds of California’s total, increased 6.9% over the previous year.

The state’s leaders, including Democratic Gov. Gavin Newsom, have struggled to make inroads against the mounting public health and political crisis — despite marshaling unprecedented taxpayer resources.

“We have a huge problem on our hands, and we have a lot of health plans and municipalities saying, ‘We need you,’” Jain said.

On the Streets

On a cloudy April morning in Long Beach, Daniel Speller navigated his mobile medical van among the tents and tarps that crowded residential streets, searching for a couple of homeless patients. A physician assistant for Healthcare in Action, Speller said he was particularly worried about the badly infected wounds they developed on their limbs after they used the street drug xylazine, an animal tranquilizer often mixed with fentanyl.

“These wounds are everywhere. It’s really bad,” Speller said. If infections progress, they can require toe, foot, or arm amputations.

“Man, this one is still so deep,” Speller said as he peeled denim pants from the swollen leg of Robert Smith, 66.

After cleaning and wrapping Smith’s leg, Speller asked him if he needed anything else. “I lost my food stamps,” Smith replied.

Within the hour, Speller’s team of social workers and nurses had summoned an Uber to take Smith to a state office, where he received a new CalFresh card.

Speller then turned his medical van onto a side street lined with more tents and cars-turned-shelters. Nick Destry Anderson, 46, was sleeping on the sidewalk and badly in need of wound care.

“I was so scared. I thought I was going to lose my leg before I met them,” Anderson said, grimacing as Speller sprayed his leg with antibiotic mist. “These people saved my life.”

Anderson reported feeling lightheaded, so Speller asked another team member to use the company credit card to get him a cheeseburger and a Sprite.

Many homeless people languish on the streets, so entrenched in mental health crises or addiction that they don’t much care about seeing a doctor or taking their medication. Chronic diseases worsen. Wounds grow infected. People overdose or die from treatable conditions.

Part of street medicine is bandaging infected sores, administering antipsychotic injections, and treating chronic diseases. Street providers often hand out drug paraphernalia such as clean needles and glass pipes to reduce sharing and prevent infections. Perhaps more importantly, these workers build trust.

Getting homeless patients established with primary care doctors and nurses — who visit them on the streets, in parks, or wherever they happen to be — can prevent frequent and expensive emergency room trips and hospitalizations, potentially saving money for insurers and taxpayers, Jain argues. Even though shelter and housing are scarce, Healthcare in Action’s goal is to get patients healthy enough to live stable, independent lives, he said.

But that’s easier said than done. In West Hollywood that week in April, Healthcare in Action clinical coordinator Isabelle Peng found Lisa Vernon, a homeless woman, slumped over in her wheelchair at a busy bus stop. Vernon is a regular at nearby Cedars-Sinai Medical Center, Peng and her colleague David Wong said.

When Peng and Wong attempted to examine her swollen leg, Vernon shouted at them and declined aid. “Antibiotics aren’t going to save my life!” Vernon yelled as a mouse scurried for the potato chip shrapnel at her feet.

They moved on to their next patient, a man they were tracking with a GPS device they sometimes affix to homeless people’s belongings. Use of the devices is voluntary. They work better than cellphones because they less often get taken by law enforcement during encampment sweeps or stolen by thieves.

“Our patients really move around a lot, so this helps us go find them when we have to get them medication or do follow-up care,” Wong said. “We have already developed rapport with these patients, and they want us to see them.”

Growing Revenue

Street medicine teams are in demand, largely because of growing public frustration with homelessness. The city of West Hollywood, for instance, awarded Healthcare in Action a three-year contract that pays $47,000 a month. The nonprofit can also bill Medi-Cal, California’s Medicaid program, which covers low-income people, for its services.

Mari Cantwell, a health care consultant who served as California’s Medicaid director from 2015 until early 2020, said Medicaid reimbursements alone aren’t enough to fund street medicine providers. To remain viable, she said, they need to take creative financial steps, like Healthcare in Action has.

“Medicaid is never going to pay high margins, so you have to think about how to sustain things,” she said.

Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023, according to Michael Plumb, SCAN Group’s chief financial officer.

Healthcare in Action and SCAN’s Medicare Advantage insurance plan generate revenue by serving homeless patients in multiple ways:

• Both are tapping into billions of dollars in Medicaid money that states and the federal government are spending to treat homeless people in the field and to provide new social services like housing and food assistance.
  
  For instance, Healthcare in Action has received $3.8 million from Newsom’s $12 billion Medicaid initiative called CalAIM, which allows it to hire social workers, doctors, and providers for street medicine teams, according to the state.
  
  It also contracts with health insurers, including L.A. Care and Molina Healthcare in Southern California, to identify housing for homeless patients, negotiate with landlords, and provide financial help such as covering security deposits.
• Healthcare in Action collects charitable donations from some hospitals and insurers, including CalOptima in Orange County and its own Medicare Advantage plan, SCAN Health Plan.
• Healthcare in Action partners with cities and hospitals to provide treatment and services. In 2022, it kicked off a contract with Cedars-Sinai to care for patients milling outside the hospital.
• It also enrolls eligible homeless patients into SCAN Health Plan because many low-income, older people qualify for both Medicaid and Medicare coverage. The plan had revenue of $4.9 billion in 2023, up from $3.5 billion in 2021.

“There’s been an incredible market fit, unfortunately,” Jain said. “You can’t walk or drive down a street in Los Angeles, rich or poor, and not run into this problem.”

Jim Withers, who coined the term “street medicine” decades ago and cares for homeless people in Pittsburgh, welcomed the entry of more providers given the enormous need. But he cautioned against a model with financial motives.

“I do worry about the corporatization of street medicine and capitalism invading what we’ve been building, largely as a social justice mission outside of the traditional health care system,” he said. “But nobody owns the streets, and we have to figure out how to play nice together.”

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

The post A California Medical Group Treats Only Homeless Patients — And Makes Money Doing It appeared first on Medika Life.