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Jonathan M. Metsch, Dr.P.H.

Clinical Professor, Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai

Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.

Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health

President & CEO, LibertyHealth/ Jersey City Medical Center (1989-2006)

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PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term hospitals, are…continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”

New PART 4 after PARTS 1, 2, and 3

PART 1. April16, 2019. Is it ethical for the public not to be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

PART 3. June 6, 2019. CANDIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.”

PART 1. April16, 2019.  Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.”” (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected-someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases – now the third-highest after New York and Illinois – has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials…

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.” (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts – funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention – are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.” (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent…

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital – or an entire town – who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois – all in the Chicago area – a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities – such as skilled-care nursing homes or long-term acute-care hospitals – and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…” (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention – the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively – infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible – the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida – the regular ones – are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

  1. A.A Mysterious Infection, Spanning the Globe in a Climate of Secrecy, by Matt Richtel and Andrew Jacobs,
  2. B.There’s a new fungal superbug, and it’s probably humanity’s fault, by Kat Eschner,
  3. C.Candida Auris: Signs And Symptoms If You’re Infected By The Deadly Superbug, by Naia Carlos,
  4. D.CDC’s secrecy of drug-resistant outbreaks in hospitals sparks patient safety debate, by Mackenzie Bean,
  6. F.Candida Auris: Here’s why it’s a superbug and what that means, by Rodrigo Torrejon,
  7. G.How To Fight ‘Scary’ Superbugs? Cooperation – And A Special Soap, by Anna Gorman,
  8. H.Culture of Secrecy Shields Hospitals With Outbreaks of Drug-Resistant Infections, by Andrew Jacobs and Matt Richtel,
  9. I.The Scary Shortage of Infectious-Disease Doctors, by Matt McCarthy,
  10. J.Healthy people not at risk of catching fungal disease, Memorial official says, by Dean Olsen,
  11. K.New Superbug, Candida Auris, Spread Around The World, As We Speak, The CDC Revealed, by Karen Miller,
  12. L.A deadly infection is sweeping some NY hospitals – but health officials won’t say where, by Betsy McCaughey,
  13. M.Editorial: Drug-resistant disease on the rise,
  14. N.Speakeasy: Bitten by the Bug, by Pratik Kanjilal,
  15. O.Candida auris Spreads Through US Hospitals, by Brenda Goodman,

PART 2. In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

“C. auris is a drug-resistant fungus that has emerged mysteriously around the world, and it is understood to be a clear and present danger. But Connecticut state officials wouldn’t tell us the name of the hospital where they had had a C. auris patient, let alone connect us with her family. Neither would officials in Texas, where the woman was transferred and died. A spokeswoman for the City of Chicago, where C. auris has become rampant in long-term health care facilities, promised to find a family and then stopped returning my calls without explanation.” (A)

“Candida auris, also referred to as C. auris, is a potentially deadly fungal infection that appears to be making its way through hospitals and long-term care facilities across the country. The New York City area and New Jersey have reported more than 400 cases over the last few years alone. Federal health authorities have declared this fungus a “serious global health threat.”” (B)

“The Council of State and Territorial Epidemiologists (CSTE) says Candida auris infections have been “associated with up to 40% in-hospital mortality.”

“Most strains of C. auris are resistant to at least one antifungal drug, one-third are resistant to two antifungal drug classes, and some strains are resistant to all three major classes of antifungal drugs. C. auris can spread readily between patients in healthcare facilities. It has caused numerous healthcare-associated outbreaks that have been difficult to control,” the CSTE said.

The CDC added, “Patients who have been hospitalized in a healthcare facility a long time, have a central venous catheter, or other lines or tubes entering their body, or have previously received antibiotics or antifungal medications, appear to be at highest risk of infection with this yeast.”

The CDC is alerting U.S. healthcare facilities to be on the lookout for C. auris in their patients.” (C)

“”It’s a very serious health threat,” said Dr. Irwin Redlener, Columbia University professor and an expert on public health policy. “It’s a superbug, meaning resistant to all-known antibiotics.”..

“These people would be in danger, so you don’t want somebody visiting the hospital not knowing that it’s around and somehow contracting the infection,” Dr. Redlener said. “That would be an utter disaster.”..

Dr. Redlener says the secrecy is a big mistake.

“If they’re rattled by Candida auris to the point where we have secrecy pacts among hospitals and public health agencies, then you’re just hiding something that obviously needs more attention and resources to deal with,” he said.

The state Department of Health says there is no risk to the general public and notes that the vast majority of patients have had serious underlying medical conditions.

Jill Montag, a spokesperson for the New York State Department of Health, issued a statement to Eyewitness News.

“We are working aggressively with impacted hospitals and nursing homes to implement infection control strategies for Candida auris,” it read.

Montag says they plan to include the name of the impacted facilities in their annual infection report, which will be released later this year.

Dr. Redlener says they have the information now and should release the names now…

“To keep that a secret is putting people in danger,” he said. “And I don’t think that’s reasonable or ethical.”” (D)

“We don’t know why it emerged,” said Dr. Maurizio Del Poeta, a professor of molecular genetics and microbiology at Stony Brook University’s Renaissance School of Medicine. At the very least, he is recommending hospitals develop stricter rules on foot traffic in and out of patients’ rooms because the microbe can be carried on the bottom of shoes.

The pathogen clings to surfaces in hospital rooms, flourishes on floors, and adheres to patients’ skin, phones and food trays. It is odorless, invisible – and unlikely to vanish from health care institutions anytime soon.

“It can survive on a hospital floor for up to four weeks,” Del Poeta said of C. auris. “It attaches to plastic objects and doorknobs.”..…

“If we don’t want it to become like Staphylococcus aureus, then we have to act now,” said Del Poeta, referring to the bacteria that became the poster child of drug resistance when it developed the ability to defeat the antibiotic methicillin, garnering the name methicillin-resistant Staphylococcus aureus, or MRSA…

“In order to get Candida auris out of a room, you have to take away everything – doorknobs, plastic items, everything. It is very difficult to eradicate it in a hospital,” Del Poeta said. He said his institution has never had a patient with C. auris…

Scientists such as Del Poeta contend it’s time for new methods of addressing resistant microbes of all kinds because infectious pathogens have developed the power to outwit, outpace and outmaneuver humankind’s most potent agents of chemical warfare, many of them developed in the 20th century.” (E)

“A case management program piloted by the New York City health department monitors patients colonized with Candida auris after they are discharged into the community and notifies health care facilities of their status, researchers reported at the CDC’s annual Epidemic Intelligence Service conference….

Patients can remain colonized with C. auris for months in a health care setting, but it is unclear if they remain colonized after discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service officer with the New York City Department of Health and Mental Hygiene (DOHMH), and colleagues.

According to Bergeron and colleagues, the state health department began referring patients colonized with C. auris to the DOHMH on Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting patient interviews and reviewing medical records to obtain relevant clinical information. They informed the patients’ providers and health care facilities about their C. auris status and infection control needs.

“We requested that facilities flag the patient in their electronic medical records to ensure that the patient has the proper precautions, if the patient were to seek care again at those facilities,” Bergeron said in a presentation. “Case mangers sent a medical alert card to the patients for them to use when encountering health care providers unaware of their infection control needs.”” (F)

“Regions are considering the use of electronic registries to track patients that carry antibiotic-resistant bacteria including carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can be challenging and requires time, effort, and resources; therefore, there is a need to better understand the potential impact…

When all Illinois facilities participated (n=402), the registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in a 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. When 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and 2.8% relative reduction in prevalence.

Implementing an XDRO registry reduced CRE spread, even when only 25% of the largest Illinois facilities participated due to patient sharing. Non-participating facilities garnered benefits, with reductions in new carriers.” (G)

“Quebec public-health authorities are bracing for the inevitable arrival of a multi drug-resistant fungus that has been spreading around the globe and causing infections, some of them fatal…

“We will definitely have cases here and there at one point,” said Dr. Karl Weiss, chief of infectious diseases at the Jewish General Hospital. “It’s almost guaranteed. The only thing is when you know what you’re fighting against, it’s always easier and we will be able to contain it a lot faster.”

C. auris poses a quadruple threat: it’s tricky to identify; it can thrive in hospitals for weeks (preying on patients with weakened immune systems); it’s resistant to two classes of anti-fungal medications; and it can cause invasive disease, with lingering bloodstream infections that are hard to treat. The mortality rate can rise as high as 60 per cent.

The pathogen has emerged at a time when hospitals in Quebec – their budgets stretched more than ever – are already struggling with antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused outbreaks. The Institut national de santé publique du Québec published a bulletin last year on steps that hospitals and long-term centres can take to prevent C. auris outbreaks.

“The problem is if you don’t identify the fungus properly, then it can slip in between your hands, and you can have an outbreak in your institution without even knowing it,” Weiss explained.

There was a lot of mis-indentification of this with other Candida (fungi); and even the automated systems in institutions that identify bacteria and yeast were mislabelling this Candida for something else. For a while, people were not aware of this auris. But now we know how to identify it.

“The first thing we did in Quebec – and this was for all the microbiology labs – is we taught all the microbiologists how to properly identify Candida auris,” Weiss continued. “All the major labs in Quebec put in place protocols.”

Weiss, who is president of the Quebec Association of Medical Microbiologists, noted that under a quality assurance program, samples have been sent to different labs to test whether the fungus is identified correctly. The results show that that labs are detecting C. auris to a high degree.

If a patient is discovered to be infected, hospital protocol dictates that the patient be isolated. During the patient’s hospitalization, the housekeeping staff must disinfect the room daily with hydrogen peroxide and other chemicals…” (H)

“Federal officials should declare an emergency over a deadly, incurable fungus infecting people in New York, New Jersey and across the country, Sen. Chuck Schumer said Sunday.

Schumer said he’s pushing the federal government to allocate millions of dollars to fighting Candida auris, which is drug-resistant and proving very difficult to eradicate…

“When it comes to the superbug, New York could use a little more help,” said Schumer. “The CDC has the power to declare this an emergency and automatically give us the resources we need.”..

Schumer said that an emergency declaration by the CDC would lead to more cases being identified with better testing, and to better tracking of the disease. It might also reduce the number of unnecessary antibiotic prescriptions, which Schumer says have helped the disease become drug-resistant…

Schumer cited other CDC emergency declarations that helped stop the spread of deadly diseases, including a $25 million award to fight the Zika virus in 2016 and $165 million given to contain Ebola in 2014.

“Every dollar we can use to better identify, tackle and treat this deadly fungus is a dollar well spent,” Schumer said.” (I)

“Other medical experts see the overuse of human antifungal medications in agriculture and floriculture as potential reasons for resistance in Candida auris, known as C. auris, and possibly other fungi.

Dr. Matt McCarthy, a specialist in infectious diseases at Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the Netherlands, are dosed with the same antifungal medications developed to treat human infections.

“Antifungals are pumped into tulips in Amsterdam to achieve flawless plants,” he said. “As a fungal expert, I know that we have very few antifungal medications, and this is a misuse of the drugs.”

Studies conducted at Trinity College in Ireland support McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from the Netherlands may be vehicles that spread drug-resistant fungi.

Trinity scientists, who examined resistance in another potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs repelled the drugs known as triazoles. The fungi became resistant because of the overuse of triazoles in floriculture. As with C. auris, drug-resistant A. fumigatus can be deadly in people with poor immunity.

When patients need treatment with triazole-class medications, the drugs don’t work because the fungi have been overexposed in the environment, McCarthy said.

He added that the use of antifungal medications in floriculture is similar to the overuse of antibiotics in the poultry and beef industries, which have helped drive resistance to those drugs.

The floriculture example is just one way that drug-resistant fungi can spread around the world. Global trade networks, human travel and the movement of animals and crops are others.” (J)

“It will take further research to determine if the new strains of C. auris have their origins in agriculture, but Aspergillus has already illustrated the perils of modern farming. Antibiotics are applied on a massive scale in food production, pushing the rise of bacterial drug resistance. A British government study published in 2016 estimated that, within 30 years, drug-resistant infections will be a bigger killer than cancer, with some 10 million people dying from infections every year.

We don’t have to end up there. Pesticide use on most farms can be greatly reduced, or even eliminated, without reducing crop yields or profitability. Methods of organic farming, even as simple as crop rotation, tend to promote the growth of mutualistic fungi that crowd out pathogenic strains such as C. auris. Unfortunately, because conventional agriculture is heavily subsidized and market prices don’t reflect the costs to the environment or human health, organic food is more expensive and faces an uphill battle for greater consumption.

Of course, improved technology could help, with drugs of new kinds or in breeding and engineering resistant strains of plants. There’s also plenty of opportunity for lightweight agricultural robots, which can weed mechanically or spray pesticides more accurately, reducing the quantity of chemicals used. But tech shouldn’t be the sole focus just because it happens to be the most profitable route for big industries.” (K)

“The recent outbreak of the so-called superbug – and other drug-resistant germs – has thrown a spotlight on locally based Xenex Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet rays to disinfect surgical suites and other environments that are supposed to be germ-free.

With the spread of C. auris, Xenex officials say they’ve seen an uptick in queries about their LightStrike Germ-Zapping Robots, which are in use at more than 400 health-care facilities around the world since manufacturing started in 2011.

These devices – often called R2Clean2, Mr. Clean and The Germinator – disinfect rooms in a matter of minutes. A dome on the top of the robot rises up, exposing a xenon bulb that emits UV light waves that kill germs on contaminated surfaces.

Bexar County-owned University Hospital has a fleet of six Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to help protect patients from infection by other patients.

“We are taking every measure possible to reduce the risk of infections, and this is an additional layer of security that bathes the room in UV-C light,” said Elizabeth Allen, public relations manager at University Health System…

Another study, recently published by a doctor at the Minnesota-based Mayo Clinic, showed that when the hospital used the robots in rooms that had already been cleaned, infection rates of another superbug – called Clostridium difficile, or C. diff – fell by 47 percent.” (L)

“It wasn’t publicized locally, but within the past few years teams of health officials at two Oklahoma health facilities took rapid actions to contain the spread of a fungal “superbug” that federal officials have declared a serious global health threat.

Only one patient at each facility was infected, and both patients recovered. But the incidents reflect the growing alarm among health officials over the deadly, multidrug-resistant Candida auris, or C. auris, which can kill 30 percent to 60 percent of those infected…

In April 2017, a team of experts from the federal Centers for Disease Control and Prevention converged on the University of Oklahoma Medical Center in Oklahoma City after a patient tested positive for the drug-resistant fungus.

About a year later, a patient at a southeast Oklahoma health facility tested positive for the germ during a routine test. In both cases, health officials isolated the patients, locked down their rooms and ordered dozens of lab tests to see if the multidrug-resistant fungus had spread…

Unlike with outbreaks in Illinois, New York and New Jersey, the potentially deadly infection was quickly contained.”..

Public knowledge about the OU Medical Center case makes it an exception. Typically, health care facilities across the nation don’t release to the public information when C. auris and other drug-resistant pathogens are found. No law or policy requires them to do so.

Patient-rights advocates maintain that the public has the right to know when and where outbreaks or even single cases occur. But health officials have routinely fought back, suggesting that it could violate patient rights and discourage patients from seeking hospital care.

But the CDC allows states to make that decision.

Burnsed said the Department of Health tries to walk a tight line between notifying the public and protecting the patient’s privacy.

He said he would be more likely to identify a facility if it’s anything more than an isolated case or if officials believed the exposure wasn’t contained.

“What we consider is if there was a risk to a broader group of individuals and if there was any evidence that there were a breach in lab controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s two cases) because we didn’t think there was a greater risk to the public, but it’s a good question to consider.”” (M)

“How many people will needlessly die from a deadly bug sweeping through New York hospitals and nursing homes before local health officials acknowledge the danger publicly – and act accordingly?..

Yet public-health officials here have been slow to let patients know in which hospitals the bug is lurking. Folks are left to take their chances. That’s outrageous.

Why are officials mum? Partly because they fear that if they disclose the information, some people who need treatment won’t go for it.

That’s a weak excuse: As McCaughey notes, there are plenty of local hospitals that aren’t plagued by Candida auris, so patients could get care and avoid the risk, if they know where it’s safe to go.

More likely, no one wants to damage the reputations (or incomes) of the affected hospitals. Yet the best way to protect those reputations is to make sure the facilities are Candida auris-free…

Meanwhile, officials say they will reveal which hospitals have the germ – in their next yearly report. But that could be months away; patients need to know now.

If neither the hospitals nor their government regulators are willing to move sooner, perhaps state lawmaker should step in and require them to do so… (N)

Infectious disease experts tell Axios they agree with a dire scenario painted in the UN report posted earlier this week saying that, if nothing changes, antimicrobial resistance (AMR) could be “catastrophic” in its economic and death toll.

Threat level, per the report: By 2030, up to 24 million people could be forced into extreme poverty and annual economic damage could resemble that from the 2008–2009 global financial crisis, if pathogens continue becoming resistant to medications. By 2050, AMR could kill 10 million people per year, in its worst-case scenario.

“There is no time to wait. Unless the world acts urgently, antimicrobial resistance will have disastrous impact within a generation.”..

By the numbers: Currently, at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people from multidrug-resistant tuberculosis, per the UN. Common diseases – like respiratory infections, STDs and urinary tract infections – are increasingly untreatable as the pathogens develop resistance to current medications.

The Centers for Disease Control and Prevention says AMR causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…

What needs to be done: Jasarevic says the economic and health systems of all nations must be considered, and targets made to increase investment in new medicines, diagnostic tools, vaccines and other interventions.”

The bottom line: Action must be taken to avoid a catastrophic future.” (O)

“A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.

Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.

What many might not realize, though, is that health care workers’ attire – including that seemingly “clean” white coat that many prefer – can harbor dangerous bacteria and pathogens.

A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.”

It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.

Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours…

It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers – including wearable sanitizer dispensers – could help reduce the spread of harmful bacteria.

Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.” (P)

  1. A.Candida auris: A mysterious fungus that nobody wants to talk about, by Matt Richtel,
  2. B.Fungal Infection Identified at More than 400 Health-Care Facilities in NYC and NJ, by Michael Ksiazek and Jeffrey Krawitz,
  3. C.CDC: Deadly, drug-resistant fungus spreading through hospitals,
  4. D.7 On Your Side Investigates: New York health officials won’t disclose facilities hit by deadly superbug, by Jim Hoffer,
  5. E.Multi-drug-resistant fungus known as C. auris affecting hundreds in New York, by Delthia Ricks,
  6. F.NYC monitors patients colonized with C. auris upon their release,
  7. G.How Introducing a Registry with Automated Alerts for Carbapenem-Resistant Enterobacteriaceae (CRE) May Help Control CRE Spread in a Region, by Bruce Y Lee, MD, MBA Sarah M Bartsch, MPH Mary K Hayden, MD Joel Welling, PhD Jay V DePasse Sarah K Kemble, MD Jim Leonard Robert A Weinstein, MD Leslie E Mueller, MPH Kruti Doshi, MBA,
  8. H.Quebec hospitals brace for C. auris, a drug-resistant fungus, by AARON DERFEL,
  9. I.Schumer urges feds to declare emergency over incurable superbug fungus, by Clayton Guse,
  10. J.C. auris, isolated in Japan a decade ago, now on global list of superbugs, by Delthia Ricks,
  11. K.C. auris, isolated in Japan a decade ago, now on global list of superbugs,by Delthia Ricks,
  12. L.San Antonio company creates robots that can combat ‘superbugs’, by Laura Garcia,
  13. M.Two Oklahoma Hospitals Fought Off Deadly Fungal ‘Superbug’, by Trevor Brown,
  14. N.It’s time for NY health officials to come clean about this killer bug,
  15. O.Drug resistance could kill 10M people per year by 2050, experts say, by Eileen Drage O’Reilly,
  16. P.Why Your Doctor’s White Coat Can Be a Threat to Your Health, by Austin Frakt,

PART 3. May 28, 2019. CADIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.”

“So far, 12 states from coast to coast have had confirmed cases of Candida auris, which has spread with particularly speed in New York, which has had more than half of the nation’s infections.

Some are even calling for the federal government to declare a national state of emergency and fund better containment of the fungus. 

Health officials there are scrambling to contain what the Centers for Disease Control and Prevention (CDC) have deemed an emerging health threat, but without stricter guidelines and screening, the fungus will only get more deadly…

Doctors sometimes struggle to diagnose fungal infections, in part because their symptoms are little different from those of bacterial infections…

‘Candida auris has the ability to develop resistance and has developed mechanisms to survive,’..

‘It’s at least starting to figure that out, and that’s obviously concerning.’

There are really only three antifungal medications in the US, so it doesn’t take long for a fungus to become wholly drug resistant.

Dr Chiller says that approximately 90 percent of strains the CDC has logged are resistant to the first-line drug, another third are resistant to a second, and between 20 and 30 percent of Candida auris infections have acquired multi-drug resistance.

‘Some are pan-resistant and those need to be isolated and stopped and we need to try to prevent them from developing,’ he says. 

Neither the CDC, other nation’s health officials or any of the 12 affected states have been able to work out where the fungus came from, or how exactly it has spread from state-to-state… 

If states don’t require their hospitals to report cases the fungal infection, the CDC may be severely underestimating the number of cases across the country.

‘It’s a bit of an uphill battle and it needs to be a really concerted effort on multiple tiers of the health care system,’ Dr Chiller says…

‘We need to stay on top of it and not let our guard down.’   (A)

“New York State health officials are considering rigorous new requirements for hospitals and nursing homes to prevent the spread of a deadly drug-resistant fungus called Candida auris.

The requirements could include mandatory pre-admission screening of patients believed to be at-risk and placing in isolation those patients who are infected, or even those just carrying the fungus on their skin.

Dr. Howard Zucker, the state health commissioner, and a fungal expert from the federal Centers for Disease Control and Prevention met last Friday in Manhattan with nearly 60 hospital officials from across the state to discuss the proposed guidelines. State health officials said they were seeking hospital input before issuing the guidelines, which they acknowledged would likely be a hardship for some institutions.

“One of our guiding objectives is to stop the geographic spread,” said Brad Hutton, the state’s deputy commissioner of public health. He said the state’s efforts to contain the spread have required significant resources — including sending individual infection specialists to investigate more than 150 cases — and that New York now needs help from individual institutions.

“We’re at a point where our response strategy needs to change,” he said. He added that he hoped the guidelines would be finalized by the end of the year, but said the state is still determining whether to apply them statewide or just to New York City and surrounding areas. It has yet to be decided whether the guidelines would be recommendations or regulatory requirements, he said…

For the moment…. hospitals are pre-screening many patients who appear to be at risk. But it can take a week to get skin-swab results back from the state laboratory, posing challenges for housing patients in isolation during the interim. Further, she said, regular testing is likely to turn up patients who are carriers but not infected, increasing the number of patients who require isolation, appropriately or not.”..

For now, much of the burden for surveillance has fallen to the state. The effort has involved the development of a fast-screening test that can analyze a skin swab in a matter of hours. But all hospitals, for the moment, have to send those tests to a state laboratory in Albany and wait several days before receiving the results, though hospitals say the backlog means tests can take a week.” (B)

“Unlike cholesterol drugs taken by millions of people for their entire lives, or $100,000 cancer drugs designed to prolong life, antibiotics are short-term drugs with limited shelf lives.

“Antibiotics are not valued by society as a high-value product, so they’re not priced very high,” said Gregory Frank, director of infectious disease policy at the Biotechnology Innovation Organization, in a phone interview.

A 2014 paper.. cited a London School of Economics study showing that while a new arthritis drug’s net present value – a measure of a drug’s net value over the ensuing decades – would be $1 billion, that of a new antibiotic would be negative $50 million…

People will buy innovative products in almost any other part of the economy, but doctors will still keep even the most innovative antibiotic behind the glass and use it only in the most dire circumstances.

“Antibiotic stewardship is a good thing, but devastating for the company developing it,” Outterson said…

Jersey City, New Jersey-based Scynexis is one company developing a treatment for drug-resistant fungal infections, ibrexafungerp, currently in several clinical trials, including one for C. auris. The company plans to file its first approval application with the FDA for ibrexafungerp next year. The drug is expected cost $450-600 per day, in line with the pricing of other antifungals, said company CEO Marco Taglietti, in a phone interview…

The race against drug-resistant infectious is ultimately a scientific one.  It’s not about finding better treatments, but newer ones in an endless war that requires always staying one step ahead of ever-evolving germs, Taglietti said. On the one hand, it’s important to practice good stewardship in order to delay resistance.

“But that creates a big challenge from an economic point of view – from the moment you launch your product after spending several hundreds of millions to develop it, it doesn’t sell,” he said.

The problem appears to be a vicious cycle of science and economics: Even existing push incentives, however generous, don’t make up for antibiotics’ lack of the large and chronic patient populations of cardiovascular disease drugs or the high prices of cancer drugs.” (C)

“Demanding that hospitals release lists of every superbug they find within their walls, however, as many transparency advocates want, is not the answer. The irony is that the hospitals that see the most superbugs are often the best ones we have, for the simple reason that they have the most sophisticated diagnostic platforms, the most powerful antibiotics and the experts to administer them.

Compelling a world-class hospital like Massachusetts General Hospital, where I saw my first superbug as a medical student, to reveal a microbe list would only freak patients out. It wouldn’t explain where the microbes came from, whether any patients were infected, and how they were cured.

In a worst-case scenario, more transparency could lead to patients avoiding medical care out of a misplaced fear of encountering drug-resistant bacteria. Hospitals might start refusing patients with certain infections, especially those coming from nursing facilities where these microbes are common, out of a concern that the patient’s bacteria could be added to the list. This would do everyone a disservice: Patients wouldn’t receive optimal care and superbugs would multiply.

But hospital administrators and government officials do need to be honest about the microbes in our medical centers and explain what is really going on. No comment will no longer suffice. People have questions and this story is not going away. To ensure that patients are well-informed, hospitals should train spokesmen to address these issues and states should revisit their reluctance to disclose information. Above all, health care workers and administrators should speak openly about the measures their hospitals are already employing to keep people safe.

I’m not particularly interested in the microbes that dwell inside of a given hospital; what matters is whether its employees follow the strict protocols that prevent these organisms from going where they shouldn’t…

Silence and evasion gives the perception that this is a problem spiraling out of control when, in fact, it’s not. An intricate tracking system exists so that epidemiologists across the country can monitor any outbreaks to ensure that proper protocols and containment strategies are implemented. We need to hear more from these superbug hunters.” (D)

“A new study published in the Journal of Occupational and Environmental Health has established protocols for containing the drug resistant Candida auris (C. auris ) in an animal facility, and by doing so, has identified four simple rules that can potentially be adopted by healthcare facilities to limit exposure to staff and patients. The study found that their double personal protective equipment (PPE), work ‘buddy’ system, disinfection and biomonitoring protocols were effective at containing high levels of C. auris infection within their animal facility, even six months after their experiments…

Before entering the animal holding and procedure rooms, staff donned a second layer of booties, gloves and gowns, which were later removed and placed in biohazard bins before exiting the rooms. Handling of infected cages and equipment was restricted to biosafety cabinets where a buddy system was implemented so that one person handed clean cages and supplies to a second person working inside the contaminated biosafety cabinet. This system-controlled workflow from clearly defined ‘clean’ to ‘dirty’ areas and allowed workers to monitor each other to ensure proper procedures were followed. Surfaces and equipment that came in contact with infected mice or tissues were treated with a strict disinfection protocol of 10% bleach followed (after five minutes) by 70% ethanol. The effectiveness of the workflow and protocols were continually monitored using swab testing on surfaces suspected to be contaminated, and as a second measure, Sabbaroud dextrose plates were placed inside the biosafety cabinet and on the floor underneath to determine whether C. auris was aerosolised within the cabinet or whether any debris contaminated the floor.

The researchers found that possible contamination came from direct contact with the infected mice or tissues but not from aerosolisation.” (E)

“A pernicious disease is eating away at Roy Petteway’s orange trees. The bacterial infection, transmitted by a tiny winged insect from China, has evaded all efforts to contain it, decimating Florida’s citrus industry and forcing scores of growers out of business.

In a last-ditch attempt to slow the infection, Mr. Petteway revved up his industrial sprayer one recent afternoon and doused the trees with a novel pesticide: antibiotics used to treat syphilis, tuberculosis, urinary tract infections and a number of other illnesses in humans…

The use of antibiotics on citrus adds a wrinkle to an intensifying debate about whether the heavy use of antimicrobials in agriculture endangers human health by neutering the drugs’ germ-slaying abilities. Much of that debate has focused on livestock farmers, who use 80 percent of antibiotics sold in the United States.

Although the research on antibiotic use in crops is not as extensive, scientists say the same dynamic is already playing out with the fungicides that are liberally sprayed on vegetables and flowers across the world. Researchers believe the surge in a drug-resistant lung infection called aspergillosis is associated with agricultural fungicides, and many suspect the drugs are behind the rise of Candida auris, a deadly fungal infection.” (F)

 “A large Candida auris outbreak at a hospital in England appears to be linked to reusable patient-monitoring equipment, a team of researchers reports today in the New England Journal of Medicine.

The outbreak in the neurosciences intensive care unit (ICU) at Oxford University Hospitals involved 70 patients who were infected or colonized with C auris, a fungus that has become increasingly resistant to azoles, echinocandins, and polyenes—the three classes of antifungals used to treat infections caused by Candida and other fungal species.

An epidemiologic investigation and case-control study by investigators from the University of Oxford, Public Health England, and elsewhere found that the most compelling explanation for the prolonged outbreak was the persistence of the organism on reusable skin-surface axillary probes, a device placed in a patient’s armpit for continuous temperature monitoring.

“Our results indicate that reusable patient equipment may serve as a source of healthcare-associated outbreaks of infection with C. auris,” the authors of the study write.” (G)

  1. A.Desperate attempts to curb a drug-resistant germ that thrives in hospitals: Dozens of doctors meet with the CDC to work out how to keep beds clean and save lives, by NATALIE RAHHAL,
  2. B.To Fight Deadly Candida Auris, New York State Proposes New Tactics, by Matt Richtel,
  3. C.New antibiotics are urgently needed, but economics stand in the way, by ALARIC DEARMENT,
  4. D.What Superbug Hunters Know That We Don’t, by Matt McCarthy,
  5. E.Potential solutions for limiting exposure to Candida auris in healthcare facilities, by TAYLOR & FRANCIS GROUP,
  6. F.Citrus Farmers Facing Deadly Bacteria Turn to Antibiotics, Alarming Health Officials, by Andrew Jacobs,
  7. G.Study links hospital Candida auris outbreak to reusable thermometers, by Chris Dall,

PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term hospitals, are…continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”

“Maria Davila lay mute in a nursing home bed, an anguished expression fixed to her face, as her husband stroked her withered hand. Ms. Davila, 65, suffers from a long list of ailments — respiratory failure, kidney disease, high blood pressure, an irregular heartbeat — and is kept alive by a gently beeping ventilator and a feeding tube.

Doctors recently added another diagnosis to her medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it arrived in the United States four years ago, with half of patients dying within 90 days.

At least 38 other patients at Ms. Davila’s nursing home, Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been infected with or carry C. auris, a germ so virulent and hard to eradicate that some facilities will not accept patients with it…

Much of the blame for the rise of drug-resistant infections like C. auris, as well as efforts to combat them, has focused on the overuse of antibiotics in humans and livestock, and on hospital-acquired infections. But public health experts say that nursing facilities, and long-term hospitals, are a dangerously weak link in the health care system, often understaffed and ill-equipped to enforce rigorous infection control, yet continuously cycling infected patients, or those who carry the germ, into hospitals and back again.” (A)

“A team of doctors at Lenox Hill Hospital has reported that a patient at their facility lost an eye due to panophthalmitis, which was caused by a Candida auris infection. In their report published in the Annals of Internal Medicine, the group describes the patient, his symptoms and treatment…

In this new finding, a 30-year-old male patient came to the trauma center at Lenox Hill Hospital complaining of eye pain and loss of vision in one eye. He was diagnosed with panophthalmitis—a condition, not a disease—in which the entire eye becomes inflamed. The doctors treating him reported that the eye was damaged beyond repair. They removed it and cleaned up the socket. Lab tests showed that the inflammation was due to Candida auris—the first such infection of its kind seen in the eye. The doctors also noted that the patient did not have a compromised immune system despite having syphilis and HIV. After dispensing treatment aimed at eradicating the fungus, the patient was discharged with instructions to return for a follow-up. But he did not do so, thus it is not known if the infection was fully cleared, or if the patient infected anyone else.” (B)

“A relatively new fungus has scientists scratching their heads in 30 countries, including India. Called Candida auris (C. auris), it has become a red flag for the medical community. Why? C. auris is drug-resistant, it can survive almost anywhere – even on sterilized medical equipment – and it is increasingly causing infections in patients in the Intensive Care Unit (ICU).

Normally Candida, a species of fungus, causes the most superficial skin infections and can be treated with over-the-counter drugs. C. auris, by contrast, does not respond well to antifungal drugs – not only is C. auris resistant to most medicines, it is actually more likely to affect patients who are given antifungal drugs to prevent common Candida infections.

First isolated in japan in 2009, C. auris was originally thought to cause ear infections. Since then, scientists have discovered that it is more invasive – and deadly. In India, the first cases of C. auris infection came to light in 2011.

According to the US-based Centres of Disease Control and Prevention (CDC), there’s a higher chance of C. auris infection in patients in a hospital set-up, and among those fitted with a central venous catheter and other devices which go inside the body. CDC data also show that patients who have received antibacterial or antifungal drugs are at the highest risk of C. auris infection than those who have not. The CDC says that 30-60% of patients infected with C. auris infection die, however, most had a prior serious illness with a compromised immune system…

 “What makes C. auris even more dangerous is that it can grow in all kinds of places – dry areas, moist places, plastic surfaces, and sterilized areas and equipment,” said Dr Archana Nirula, medical officer,…

It’s an understatement to say that C. auris is quirky. Even as scientists are throwing all their weight behind research to find a cure, doctors are banking on good old hygiene and echinocandins – an antifungal drug that seems to work in select cases of C. auris infection. ICMR has even recommended that doctors schedule any interventional procedures for C. auris-infected patients at the end of the day – C. auris can survive sterilization and the infection can spread to other patients through medical equipment.” (C)

“When this deadly fungus first emerged in America, it was not disclosed to the public for a lengthy period of time. Then, when details of deaths in hospitals due to the superbug went public, the national news media reacted but then went silent. Why?…

“Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny.”

“Who’s speaking up for the baby that got the flu from the hospital worker or for the patient who got MRSA from a bedrail? The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change,” Arthur Caplan, PhD…

 “The average person calls Candida infections yeast infections,” William Schaffner, MD, Professor and Chair, Department of Preventative Medicine at Vanderbilt University Medical Center, told Prevention. “However, Candida auris infections are much more serious than your standard yeast infection. They’re a variety of so-called superbugs [that] can complicate the therapy of very sick people.”

The CDC reports that, as of May 31, 2019, there have been a total of 685 cases of C. auris reported in the US. The majority of those cases occurred in Illinois (180), New Jersey (124), and New York (336). Twenty more cases were reported in Florida, and eight other states—California, Connecticut, Indiana, Maryland, Massachusetts, Oklahoma, Texas, and Virginia—each had less than 10 confirmed cases of C. auris.

The CDC states the infection seems to be most prominent among populations that have had extended stays in hospitals or nursing facilities. Patients who have had lines or tubes such as breathing tubes, feeding tubes, or central venous catheters entering their body, and those who have recently been given antibiotics or antifungal medications, seem to be the most vulnerable to contracting C. auris…

The fungus typically attacks people who are already sick or have weakened immune systems, which can make it challenging to diagnose, the CDC notes. C. auris infections are typically diagnosed with special clinical laboratory testing of blood specimens or other body fluids. Infections have been found in patients of all ages, from infants to the elderly…

The CDC states that it and its public health partners are working hard to discover more about this fungus, and to devise ways to protect people from contracting it. Average healthy people probably don’t need to worry about becoming infected with Candida auris. However, individuals who are at high risk, and healthcare professionals, microbiologists, and pathologists, should be on the alert for this new superbug strain of fungus.” (D)

“A new report from the US Centers for Disease Control and Prevention (CDC) warns health care organizations and providers that overseas hospitalization and carbapenemase-producing organism (CPO) colonization or infection should be seen as warning signs for the presence of Candida auris.

The warning, published in the CDC’s Morbidity and Mortality Weekly Report, comes after a case in Maryland last September in which a patient was admitted to the hospital with multiple CPO colonizations/infections. The patient had previously spent a month in a Kenyan hospital after suffering a cerebral hemorrhage while visiting the African country…

The CDC recommends that anyone who has been hospitalized overnight overseas in the past 12 months be screened for C auris. The agency also recommends contact precautions and CPO screening for any patient with an overnight overseas hospital stay in the previous 6 months.

Richard B. Brooks, MD, of the Division of Healthcare Quality Promotion at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, told Contagion®  that overseas travel is an important risk factor for C auris, but he said awareness of the link between C auris and receiving care overseas varies from hospital to hospital and provider to provider.

In the case of the Maryland patient, public health officials were already on alert since the health department had previously found CPOs and C auris in a patient who had been hospitalized in India.

Unfortunately, Brooks said, many hospitals miss opportunities for screening because they are unaware that a patient has traveled overseas…

If a patient is indicated for C auris screening, Brooks cautioned that most routine hospital testing platforms can easily misidentify C auris, and he noted that commercial testing is not currently available to hospitals. However, Brooks said the CDC’s Antibiotic Resistance Laboratory Network will perform the test free of charge. Health care facilities can request testing through their state health departments. The test itself is simple, he said.

“Screening for C auris colonization requires gently rubbing a cotton swab over a patient’s skin in their axillae (armpits) and groin areas, and is not particularly difficult, invasive, or time-consuming,” he said.” (E)

“Prevention of invasive Candida infections requires antibiotic stewardship, improved maintenance practices for central venous catheters, and targeted antifungal prophylaxis.

Multidrug-resistant Candida auris is an urgent antimicrobial resistance threat and the key method of C auris prevention is strict adherence to infection control measures, according to a short opinion paper published in the Annals of Internal Medicine.

Unlike other Candida spp, C auris is commonly transmitted between patients in healthcare settings and primarily colonizes the skin and nares. Currently, there are no known strategies for C auris decolonization…

Although early identification is key to controlling C auris transmission, “many laboratories lack mycology capacity, and those that have it may not routinely determine yeast species, even in sterile site isolates” according to the researchers.

Antibiotic stewardship, improved maintenance practices for central venous catheters, and targeted antifungal prophylaxis are all required for preventing invasive Candida infections; however, the key difference for C auris prevention is strict adherence to infection control measures.

While much more needs to be learned about C auris, “preventing the spread of this organism is a priority that requires bolstering laboratory detection capacity, strengthening public health surveillance, and improving infection control practices, especially in postacute care settings,” concluded the researchers.” (F)

“In any other year, it seems, this would be big news: A drug-resistant yeast is spreading around the world, behaving like a cross between a fungus and a bacterium. It lodges itself so tenaciously in hospital environments that cleanups can resemble demolitions. It can’t be easily identified with standard laboratory methods, and it kills 30% to 60% of the people it infects.

The yeast, Candida auris, “is a creature from the black lagoon,” according to Dr. Tom Chiller, who heads the Mycotic Diseases Branch of the U.S. Centers for Disease Control and Prevention. At the 20th Congress of the International Society for Human and Animal Mycology in Amsterdam in 2018, he also noted that C. auris is ” more infectious than Ebola.” Indeed, by the end of May C. auris had been reported in more than 30 countries, according to the CDC.

This sounds like the stuff of nightmares, or material for an update to the 2011 medical action thriller, “Contagion.”

Surprisingly, Chiller seems unperturbed about the secrecy, stating that C. auris “is not something I want the general public to go home and be concerned about.”..

This is why transparency is critical. When Chiller and others argue that the general public doesn’t need to be concerned about C. auris, they are drawing a distinction between concerns of public health and matters of personal health. Obviously these are different, but they are also linked.

Secrecy in medicine has a long and sordid history, including the familiar scandals around experimentation, mistakes and malpractice, and price gouging. Healthcare, pharmaceutical, and agricultural organizations, ever sensitive to their reputations and the bottom line, respond to public pressure.” (G)

“Facing the spread of the deadly and highly resistant Candida auris fungus, New York might require nursing homes and hospitals to conduct pre-admission screenings and isolate carriers and the infected.

The considerations by New York State health officials were reported by the New York Times last week. The newspaper reported that Howard Zucker, M.D., the state health commissioner, and a fungal expert from the federal Centers for Disease Control and Prevention met this month with nearly 60 hospitals to discuss possible guidelines.

New York has handled 331 cases of C. auris since it was first identified in 2009. It spreads easily, is extremely resistant to drug treatments, is hard to kill on surfaces and may spread in the air. While scientists are working on ways to short-circuit the fungus itself, New York wants to stop the costly geographic spread.

“We’re at a point where our response strategy needs to change,” Brad Hutton, the state’s deputy commissioner of public health, told the Times. He said it remains undecided whether final guidelines, expected by year’s end, would apply statewide or only in New York City.

Hospitals and other providers have raised concerns about the cost and capacity for rapid testing, while isolation for carriers who aren’t actively infected could take away beds needed by others.” (H)

“”To keep that a secret is putting people in danger,” said Dr. Irwin Redlener, a Columbia University professor with an expertise in Public Health policy. “And I don’t think that’s reasonable or ethical.”

Palm Centers declined comment on repeated questions by Eyewitness News regarding the presence of Candida auris at the facility.

The New York State Department of Health provided a statement about its efforts to contain the bug.

“The Department of Health has made controlling the spread of C. auris a top priority and has conducted extensive training and education on infection control policies and procedures for Palm Gardens and other nursing home providers throughout this region. We take complaints regarding quality of care extremely seriously and ensure all appropriate steps to protect the health and well-being of nursing home residents,” said Jeffrey Hammond, NY Department of Health spokesperson.

Hammond added that a list of facilities with C. auris cases will be released later this year in the 2018 Hospital Acquired Infection Report.” (I)

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SEPTEMBER 11, 2001. PART 1. Military helicopters and jets were overhead, as President Bush was getting ready to leave NYC. PART 2. LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral”…

PART 1. *written by Jonathan M. Metsch on September 14, 2001; published in the Jersey Journal on September 18, 2001

Military helicopters and jets were overhead, as President Bush was getting ready to leave. The plumes of smoke from the World Trade Center were still billowing skyward.

Suddenly a huge white military hospital ship with four Red Crosses steamed by and docked right across river. I thought how this hospital ship brought the war even closer to home but mostly about how the hospitals in Hudson County had responded and performed so magnificently.

Liberty HealthCare System is comprised of Jersey City Medical Center, Greenville Hospital, and Meadowlands Hospital Medical Center. The Medical Center, the County’s Trauma Center, treated 175 patients. Greenville treated 11 patients and processed over 500 volunteers who wanted to give blood; Greenville had originally been asked by the Red Cross to be a blood center but this was changed early on so donor information was passed (every volunteer was “typed and matched”) to the blood collection centers. Meadowlands treated 7 patients and was preparing to be a command center given its heliport; late Tuesday night Governor DiFrancesco used the heliport to depart from his visit to the triage center at Liberty State Park.

Every hospital in the County provided emergency services to victims. According to the Jersey Journal: Palisades Medical Center treated 12 patients; St. Francis Hospital treated 67 patients; Christ Hospital treated 54 patients; St. Mary Hospital treated 74 patients. Bayonne Hospital treated 58 patients.

At the Medical Center staff watched from windows the attack on the World Trade Center, then immediately went on Disaster Alert. Over 150 physicians covering all medical and surgical specialties were in the building as they are every day, and over 1000 other staff joined predetermined teams – trauma and surgery in the emergency room, and “walking wounded” in the auditorium. The library was organized for aftercare and rooms were set up for family members arriving from all over the metropolitan area. The injured started arriving around 10AM and suddenly, and sadly, everything stopped about 6PM. We hope and waited for more patients, and still wait “on alert”, our hope fading.

Since the New York City Command Center was in the World Trade Center complex and destroyed, good information was not available. We were told to expect somewhere between 2000 and 5000 injured.

Many others contributed to our success in handling the medical response to this act of war:

– Over 200 ambulances simply appeared from all over the state to assist. They were restocked from Medical Center inventory and dispatched by Medical Center EMS.

– New Jersey Commissioner of Health and Senior Services George DiFerdinando was in contact with us immediately and made sure we were re-supplied, and developed a plan with whereby trauma centers outside of Hudson County were on high alert so patients could be transported there to prevent Hudson County hospitals from being overwhelmed.

– Every hospital in the New Jersey was on disaster alert with elective admissions and surgery cancelled, and disaster teams ready until late Tuesday evening.

– Providers of food, IV solutions, medications, surgical supplies, and much more sent in truckloads of supplies without being asked.

– Volunteers poured in to help us in any way possible. For example with their help a “Hot Line” was set up at the Medical Center with up-to-date information on all disaster victims seen at New Jersey hospitals. This “Hot Line” was soon designated as “official” until the New York City Command Post was reestablished.

– Hudson Cradle opened its doors, wanting to help, wanting to serve.

– Mayor Cunningham and Jersey City police and fire officials coordinated all local efforts while supporting the recovery in New York City and securing the waterfront where victims were arriving by ferry in great numbers to several sites including Exchange Place and Liberty State Park. I know public officials in Hoboken, Secaucus, Bayonne and Weehauken did the same.

– And untold numbers were praying for the victims and those providing care – we could feel those prayers.

How can you help? Volunteer to give blood; blood will be needed for weeks and months to come. If you can, make a cash donation to help the families of those killed in this tragedy. Certainly go to community vigils and prayer services. Befriend someone who does not look like you and let them know that all Americans share this pain together and that the beauty of America is that we all came from somewhere else, and now live and work harmoniously side-by-side.

On a practical level we and other local hospitals can use your help. If you are a mental health worker and want to help with World Trade Center disaster Crises Counseling in hospitals, schools, and offices please call us. If you are a nurse who works outside the County or doing something else right now – particularly emergency room, critical care and operating room nurses, though all nurses are welcome – and want to be on our roster of volunteers for future emergencies please us. And if you just want to join the cadre of volunteers at our hospitals please call us. Please call 201 915-2048.

Finally I want to thank all the staff at Liberty, who once again, provided services so well. They acted heroically while worried about missing family and friends, and their children at home who had to cope with this tragedy without them nearby. I am honored to work with you.

PART 2. Confidential September 11, 2001 LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey gubernatorial campaign issue

Since Jersey City Medical Center was the New Jersey anchor in the response, I prepared a confidential Lessons Learned memorandum in preparation for a Debriefing Meeting called by the Democratic Party candidate for Governor.

As a courtesy I provided a copy of the memorandum to Bret Schundler, the former Mayor of Jersey City who was out-of-the country on September 11th and could not get back for almost a week. He was the Republican Party candidate for Governor. I forget that “No good deed goes unpunished” and Schundler widely circulated the document as a campaign issue.

“Rookie” mistake! Read the article below. What would you have done differently?

New York Times. September 22, 2001

Schundler Assails New Jersey’s Response to Terrorist Attack


Making the World Trade Center disaster the focus of his campaign for governor, Bret D. Schundler is criticizing New Jersey’s response to the attack and has released his own plan to improve the state’s defenses against terrorism and its preparedness for future emergencies.

Mr. Schundler, the Republican candidate, has said that both the State Police and the National Guard reacted slowly and mismanaged their resources after the Sept. 11 attack, and that flaws in New Jersey’s emergency-management system made it difficult to coordinate the efforts of hospitals, ambulance crews and other volunteers.

Mr. Schundler, the former mayor of Jersey City, is now calling for bolstering New Jersey’s defenses, including restoring to the nation’s air-defense system an Air National Guard fighter wing that is stationed in Atlantic City and which, until two years ago, had two F-16’s ready to scramble 24 hours a day. He said New Jersey should conduct a thorough inventory of sensitive installations, like power plants, reservoirs and chemical factories, and immediately enhance security at Newark Airport and the the Hudson and Delaware River crossings.

He is also proposing an array of measures to improve the state’s response to emergencies, like maintaining rosters of doctors, nurses, engineers and others who might be needed in the case of another terrorist attack.

Mr. Schundler’s aides described his proposals as an attempt to provide leadership where it was needed and denied that he was trying to jump-start his campaign, which has stalled along with most of the political machinery in New Jersey.

But in critiquing the state agencies, hospitals and other institutions that responded to the attack — while the smoke is still rising from ground zero and many voters are still awaiting the remains of their loved ones — Mr. Schundler is running a huge risk: that he could be seen as trying to make hay out of a national tragedy.

”This is not a political exercise,” said Richard McGrath, a spokesman for James E. McGreevey, the Democratic candidate. ”Jim McGreevey’s been working in a quiet way to assimilate as much information as possible to address emergency needs and prevent future catastrophes,” Mr. McGrath said. ”This terrorist incident has had a profound effect on all Americans, and we don’t intend to parcel it out with any political agendas.”

In a telephone interview he initiated on Thursday, Mr. Schundler described a number of ways in which the state’s response to the attack had apparently broken down. For instance, he said he had been told by a police official in Jersey City that the State Police troopers who set up an operations center in Liberty State Park ”didn’t do much of anything — they just sat there.”

Mr. Schundler added that the troopers’ ”inaction” had forced the city’s police department to coordinate the supply effort for emergency workers, and said that troopers did not even arrive in Jersey City until 4:30 p.m. on the day of the attack.

Officials of the State Police and other agencies today briefed Mr. Schundler and Mr. McGreevey about their efforts. But on Thursday, Col. Carson Dunbar, the superintendent of the force, said there had been numerous tussles over turf in the hours after the attack, which were compounded by the loss of a radio-transmission tower at the World Trade Center, and which could have led to crossed signals about troopers’ assignments. But Colonel Dunbar said that state troopers were on the scene in Jersey City almost immediately after the attack. For instance, he said, one marine unit was among the first to ferry the injured to safety in New Jersey.

On Thursday, Mr. Schundler also released a five-page memorandum about breakdowns in the state’s response system that was prepared by Jonathan M. Metsch, president and chief executive of Jersey City Medical Center, which treated 175 people hurt in the attack.

The memo noted that police from outside Jersey City had prevented staff members from getting to the hospital; that National Guard troops who drove ambulances to the hospital ”had no leadership and provided no help”; that the blood donor system ”did not work”; and that it ”took too long” to prepare a list of the injured being treated at New Jersey hospitals, meaning each hospital was inundated with thousands of calls.

Dr. Metsch, reached today, said he had written the memo for state health officials, that it amounted only to his own impressions, and that he had done so merely to ensure that lessons would be learned, not to assess blame. He said he provided a copy to Mr. McGreevey on Wednesday after a private meeting of hospital executives that Mr. McGreevey had called to inquire about the response to the twin towers attack and ways to improve New Jersey’s readiness.

Dr. Metsch said he then provided a copy to Mr. Schundler, whom he called a friend, as a courtesy. But he said he had not expected the memo to be released to the public. ”These were off-the-record observations,” he said, adding that over all, New Jersey performed admirably.

But Bill Pascoe, Mr. Schundler’s campaign manager, said Dr. Metsch had not asked Mr. Schundler to keep the memo confidential. And he said Mr. Schundler’s use of it transcended politics.

”If the U.S. responds anytime in the next few days or weeks, we may be facing an immediate counterattack from the terrorists,” Mr. Pascoe said.

”We don’t have the luxury of time to let the dust settle. We have to use this event and our response to it right now as a learning exercise. What have we learned about what we did right and did wrong? What can we do better? That’s the point, and that’s the job of a leader.”

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PART 3. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because I did not know when a new heart would become available.

New PART 3 after PARTS 1&2

PART 1. July 29, 2018. SURPRISE MEDICAL BILLS. Write in AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital admission documents accepting financial responsibility for your care.

PART 2. May 20, 2019. OUT-OF-NETWORK BILLS. Private Equity is a Driving Force Behind Devious Surprise Billings

PART 1. July 29, 2018. SURPRISE MEDICAL BILLS. Write in AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital admission documents accepting financial responsibility for your care.

“No Surprise Charges” is one of the key Lessons Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS (Penguin Press, 2017). “Hospitals in your network should also be required to guarantee that all doctors who treat you are in your insurance network.”

We have all harshly experienced or heard about under-the counter out-of-network hospital charges:

“A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.”(A)

A study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an “out-of-network” doctor – and thus exposed to additional charges not covered by their insurance plan.” (B)

Here is a brief case study:

“When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma. Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.” (C)

So what can you do to avoid out-of-network charges?

– Speak with a practice representative before being seen to understand the costs of seeing your doctor on an out-of-network or a cash basis. (DOCTOR note: maybe you need to leave and go to an in-network physician instead)

– If you need additional services, such as surgery, imaging or physical therapy, ask your doctor to refer you to an in-network facility to keep your costs down. (D)

A New York law is a great start toward transparency to reduce out-of-network surprises.

Under a recent New York law, Hold Harmless Protections for Insured Patients, “… patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.

A bill is considered a surprise if consumers receive services without their knowledge from an out-of-network doctor at an in-network hospital or ambulatory surgical center, among other things. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out of network and may result in higher out-of-pocket costs, it’s considered a surprise bill.” (E)

“Advocates for patients, senior citizens, labor unions, and businesses hailed Gov. Phil Murphy’s signing of a complex and controversial measure designed to curb the impact of costly “surprise” medical bills in New Jersey. Supporters said the law, nearly 10 years in the making, is the strongest of its kind nationwide…

The Democratic governor, who pledged his support for the bill in March, said the law closed a loophole to protect patients and make healthcare more affordable; sponsors called it the right thing to do to protect vulnerable residents. “We have put patients first. We have made clear that New Jersey stands for transparency when it comes to health care,” …

The reform is designed to protect patients, businesses, and others who pay for medical care from the high-cost bills associated with emergency or unintentional care from doctors or other providers who are not part of their insurance network. The law requires greater disclosure from both insurance companies and providers – so patients are clear on what their plan covers – ensures patients aren’t responsible for excess costs, and establishes an arbitration process to resolve payment disputes between providers and insurers, a mechanism intended to better control costs…

“It’s a solution that is fair to healthcare providers and consumers alike because it strikes a balance between providing reasonable compensation to facility-based providers, while protecting consumers from unexpected, nonnegotiable bills that drive health insurance premiums higher,” said NJBIA president and CEO Michele Siekerka. “This was an extremely difficult and complicated issue, and NJBIA commends the governor and the bill sponsors who worked hard to address the concerns of all stakeholders.”” (F)

A price transparency RFI released by the agency this week asks for input on how CMS might develop consumer-friendly policy. In a request for information announced Thursday, the Centers for Medicare & Medicaid Services asked whether providers and suppliers should be required to tell patients, in advance, how much a given healthcare service will cost out-of-pocket. If the agency were to move forward with a price transparency requirement on physician practices, it could prove controversial. Many doctors say they themselves lack the training they would need to have effective conversations about how much the healthcare services they provide will ultimately cost patients.

But CMS has repeatedly indicated that it aims to get more pricing information to consumers one way or another. “We are concerned that challenges continue to exist for patients due to insufficient price transparency,” the agency wrote in its RFI, which is included in proposed revisions to the Physician Fee Schedule, Quality Payment Program, and other policies for 2019…

In order to determine what additional actions may be appropriate to connect consumers with accessible price information, the CMS price transparency RFI includes a variety of questions, including the following: How should the phrase “standard charges” be defined in various provider and supplier settings?

Which information types would be most useful to beneficiaries, and how can providers and suppliers empower consumers to engage in price-conscious decision-making?

Should providers and suppliers have to tell patients how high their out-of-pocket costs are expected to be before providing a service?” (G)

“Patients are at a higher risk of receiving surprise medical bills on Affordable Care Act exchanges, according to a new report.

In 2018, more than 73% of plans available in the exchange marketplace offered restrictive networks, compared with 48% in 2014, according to the report (PDF) commissioned by Physicians for Fair Coverage. PFC is a nonprofit alliance of physician groups which advocates for ending surprise insurance gaps and improving patient protections…

“This research confirms what patients and physicians across the country have known for some time,” said PFC President and CEO Michele Kimball in a statement. “Insurers have been systematically narrowing their networks and increasing premiums, creating surprise insurance gaps that patients don’t realize exist until it’s too late. While insurers are making record profits, patients are paying more for less.”

The coalition, which includes tens of thousands of emergency physicians, anesthesiologists and radiologists from across the country, is pressing for more states to adopt legislation to solve the problem of surprise medical bills. The problem often occurs when a patient seeks care at an in-network hospital but is then surprised the doctor treating them is out of their insurance company’s network-a fact they usually find out when they get the doctor’s bill.

“When it comes to health care, nobody likes a surprise. This study confirms what we’ve been hearing from patients for years: there is no real way for patients to avoid a ‘surprise’ medical bill, even when they’re insured and try to stay in-network. We need a transparent healthcare system designed for patients, not profits,” Rebecca Kirch, executive vice president of healthcare quality and value at the National Patient Advocate Foundation, said in a statement…

The best estimates indicate that 1 out of 7 times someone goes to the emergency department, they are going to be stuck with a surprise bill.” (H)

A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.

So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.

The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.

How should we respond? (I)

“In the absence of laws barring balance bills and surprise bills, there are steps hospitals and health plans can take to protect consumers from medical debt. The Healthcare Financial Management Association urges hospitals to inform patients that they may be eligible for financial assistance provided directly by the hospital and make clear to patients what services are and are not included in their price estimates. Hospitals also need to communicate better with uninsured patients about medical costs and options for sharing costs..

Health plan best practices include helping members estimate expected out-of-pocket costs and sharing price information for providers in a given region.

Beyond that, hospitals need to double down to ensure they have contracts with as many in-network providers as possible. “It requires the physicians, hospitals, health plans all working together to make sure that everybody’s in-network or, if they’re not, the patient knows that clearly up front,” says Rick Gundling, HFMA’s senior vice president for healthcare financial practices. “It’s kind of a three-legged stool.”

Consumers also need to become savvier when it comes to costs of medical care. Most people do see providers in their network, says Gupta. However, “because of their high-deductible health plan, they often don’t recognize until they get hit with a bill that the same MRI might be $3,000 after the deductible at a local hospital that is convenient for them versus $1,000 a mile down the street at an imaging center,” he adds.” (J)

“Cooper works as a physician assistant and hears about medical billing problems all the time.

So when she initially found out she was pregnant, this health care provider did everything she could to make sure anyone associated with her pregnancy would be considered what’s referred to as “in-network.”

She contacted her insurance company, Aetna, and she also contacted Banner Gateway Hospital, the hospital where she planned to give birth. The hospital then sent her written confirmation that she had nothing to worry about.

“She said, ‘Send me a picture of your insurance card front and back and I’ll double check that you’re covered.’ And, she sent me back an hour later saying, ‘Yes, you are in network,'” Cooper said.

Cooper eventually delivered her little girl at Banner Gateway Hospital. But, not long after, Cooper started getting a number of large “out-of-network” medical bills.

“Aetna then sent me back something that said, ‘No you are out-of-network’ and that’s how everything started to trickle through,” she said.

“Out-of-network.” How could that happen? Remember, she got written confirmation from Banner Gateway Hospital indicating she was “in-network.”…

When she added them all up, her medical bills came to around $18,000, money she shouldn’t have been responsible for. Still, she says she wasn’t getting any resolution…

We asked them to review Cooper’s case and after they did, they acknowledged there was a mistake.

As a result, Aetna reprocessed all of Heather’s bills as “in-network.”..

That means Cooper will now only have to pay just $750 out of pocket, the cost of her deductible rather than $18,000. Cooper said she couldn’t be happier and says it all happened with the help of 3 On Your Side.” (K)

“On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.

There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family – tourists from South Korea – to Zuckerberg San Francisco General Hospital.

The doctors at the hospital quickly determined that baby Jeong-whan was fine – just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.

Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” which sometimes is known as “a trauma response fee.”

Update: After this story was published on June 28, Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma response fee charged for Park Jeong-whan’s visit to the hospital. In a letter, the hospital’s patient experience manager said the hospital did a clinical review and offered “a sincere apology for any distress the family experienced over this bill.” Further, the hospital manager wrote that the case “offered us an opportunity to review our system and consider changes.” (L)

“The health insurer Anthem is coming under intense criticism for denying claims for emergency room visits it has deemed unwarranted…

The insurer initially rolled out the policy in three states, sending letters to its members warning them that, if their emergency room visits were for minor ailments, they might not be covered. Last year, Anthem denied more than 12,000 claims on the grounds that the visits were “avoidable,” according to data the insurer provided to Senator Claire McCaskill, a Democrat from Missouri, one of the affected states.

But when patients challenged their denials, Anthem reversed itself most of the time, according to data the company gave Ms. McCaskill. The report concludes that the high rate of reversals suggests that Anthem did not do a good initial job of identifying improper claims, meaning some patients who did not challenge their denials may have been stuck paying big bills they should not have been responsible for.” (M)

  1. A.Surprise Medical Bills by Karen Pollitz,,
  2. B.Many get hit with surprise ‘out-of-network’ bill after emergency rooms: Study” by Dan Mangan, CNBC,
  3. C.When Out-Of-Network Charges Pop Up, Try An Appeal, by Michelle Andrews, NPR,
  4. D.What It Means If Your Doctor is Out of Network, by Sergio Viroslav, Angie’s list,
  5. E.N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges by Michelle Andrews, KHN
  6. F.Governor Signs Nation’s Strongest Law on ‘Surprise’ Medical Bills, by Lilo H. Stainton,
  8. H.Patients on ACA plans at higher risk for surprise bills, physician coalition says, by Joanne Finnegan,
  9. I.Let’s tell the truth about what’s going on, by Michael Kirsch,
  10. J.Some patients fight back against surprise medical bills, by Meg Bryant,
  11. K.Gilbert mom fighting medical bills she says she shouldn’t owe, by LiAna Enriquez,
  12. L.A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill, by Jenny Gol and Sarah Kliff,
  13. M.A Health Insurer Tells Patients It Won’t Pay Their E.R. Bills, but Then Pays Them Anyway,

PART 2. Private Equity is a Driving Force Behind Devious Surprise Billings,

I thought I was a good OUT-OF-NETWORK detective and could avoid SURPRISE MEDICAL BILLS. Not so! Recently I switched physicians within a sub-specialty practice group. The first MD took my Medicare “GAP” insurance but the second did not. This lesson already cost me $1,000 versus an in network cost of probably $200. One can never be too vigilant!

“The expectant mother was in labor at South Shore Hospital when she requested a common pain medicine, which was administered by an anesthesiologist. Home with a newborn days later, she was surprised when a bill arrived from the doctor’s group for $2,143.44.

Another patient who went to Emerson Hospital’s emergency department for what turned out to be a broken rib also received a surprise bill: $300.91, for the services of the doctor who read the X-ray…

Patients should not have to “contact their health plan and complain,” said David Seltz, executive director of the Massachusetts Health Policy Commission, which monitors health care spending in the state. “Through no fault of their own they are being put in this situation.”

An analysis by the policy commission found that 10,000 Massachusetts patients in just one year may have received surprise bills for so-called out-of-network care, and policy experts believe that figure underestimates the extent of the problem…

More than 35 percent of complaints filed with Healey were over out-of-network charges, which can be up to 200 percent higher than what insurers pay in-network doctors. Among the physicians that were outside the patients’ insurance networks were anesthesiologists assisting in colonoscopies and emergency medicine doctors repairing broken bones and treating heart attacks, something that frustrated patients told Healey’s office they had no way of knowing in advance. Radiologists and pathologists also directly billed patients out-of-network charges.

It’s not unusual for a hospital to have practitioners working in their facilities who are not covered by all their agreements with insurers, a technicality that is often not apparent to patients.” (A)

” (Trump)” In my State of the Union address, I asked Congress to pass legislation to protect American patients. For too long, surprise billings – which has been a tremendous problem in this country – has left some patients with thousands of dollars of unexpected and unjustified charges for services they did not know anything about and, sometimes, services they did not have any information on. They weren’t told by the doctor. They weren’t told by the hospitals in the areas they were going to. And they get, what we call, a “surprise bill.” Not a pleasant surprise; a very unpleasant surprise.

So this must end. We’re going to hold insurance companies and hospitals totally accountable.” (B)

“But physician advocacy groups, including the American Medical Association (AMA) while applauding the effort to eliminate surprise bills, expressed some concern that a simplified approach to a complex problem could have unintended consequences for healthcare delivery…

“We agree with the president that patients should not be responsible for coverage gaps and for any costs beyond their in-network cost sharing when they do not have an opportunity to choose an in-network physician,” said Barbara L. McAneny, MD, AMA’s president in a statement. “We also agree that physicians and hospitals should be transparent about their costs, and payers should offer transparency about their networks, scope of coverage, and out-of-pocket costs. In addition, insurers should be held accountable for their contributions to the problem and ensure network adequacy, adherence to the prudent layperson standard for emergency care in current law, and reasonable cost-sharing requirements.”” (C)

“Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), the top Democrat and Republican on the House Energy and Commerce Committee, have jointly released a draft bill that would prevent patients from facing unexpected charges after they go to the emergency room or receive other non-emergency medical care…

The Pallone and Walden bill takes a multi-pronged approach to ending surprise medical bills:

Health insurers would be required to treat out-of-network emergency care as in network for their enrollee’s cost-sharing and out-of-pocket obligations. So patients wouldn’t have to pay any more for receiving emergency treatment at an out-of-network hospital than they would at an in-network one.

Balance billing – when a health care provider sends a patient a bill charging them whatever the difference is between the price set for a service by the provider and the price the health insurer is willing to pay – would be prohibited.

Insurers would have to make a minimum payment to out-of-network providers for their enrollee’s care, based on the price the insurer pays to nearby in-network providers… (D)

“These protections would apply to all out-of-network emergency services and to all out-of-network nonemergency services received at an in-network facility from “facility-based providers,” which the bill defines to include anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, and any additional provider types specified by the Secretary of Health and Human Services (HHS). Other provider types would still be allowed to treat patients on an out-of-network basis in nonemergency situations if they met the strong notice and consent requirements detailed in the discussion draft. Limiting notice and consent exceptions to physician specialties that patients typically actively choose strikes a sensible balance. It preserves patients’ ability to seek out-of-network care in circumstances where it is appropriate, while mitigating the risk that the flood of paperwork involved in seeking medical care will result in some patients consenting to out-of-network billing without understanding what they are consenting to or whether they have a reasonable alternative.” (E)

“A new draft bill released this morning sets up a so-called “baseball-style” arbitration process for providers and plans as an option to settle payment disputes, POLITICO’s Rachel Roubein writes. Today’s draft comes after Sens. Bill Cassidy (R-La.), Michael Bennet (D-Colo.) and four others spent eight months refining legislation first introduced in September. More for Pros.

– Today’s legislation prohibits balance billing in three instances, Rachel writes. (1) For emergency care, (2) during elective care at an in-network facility but when a service is performed by an out-of-network provider and (3) when a patient needs additional medical care after an emergency at an out-of-network facility but can’t travel elsewhere.

– The most contentious part of addressing surprise medical bills: the payment. Under the new bill, providers would automatically be paid the median in-network rate. But they can dispute that, initiating a so-called “baseball-style” arbitration process, where mediators will base decisions on “commercially reasonable rates” (the in-network rates for that area and not actual charges).” (F)

“The House of Representatives and the Senate have unveiled dueling legislation aimed at surprise billing, and the two are split on one key element: arbitration.

The House bill (PDF), which was introduced earlier this week by Reps. Frank Pallone, D-New Jersey and Greg Walden, R-Oregon, would require insurers to cover out-of-network emergency care at in-network rates and would ban balance billing.

Balance billing most often occurs in emergency departments or during elective surgery, when a patient goes to an in-network facility but is treated by an out-of-network clinician, typically an anesthesiologist or radiologist.

The Senate’s bill, however-which is backed by Sens. Bill Cassidy, R-Louisiana, and Maggie Hassan, D-New Hampshire-would include a “baseball-style” arbitration program to mitigate disputes, alongside similar elements to the House iteration.” (G)

“The administration said its top priority is to make sure patients no longer receive separate bills from out-of-network doctors, an approach known as a “bundled payment.”..

Vidor Friedman, president of the American College of Emergency Physicians, said a bundled payment puts too much pressure on hospitals to contract with physicians, essentially making hospitals take on the role of insurer.

“It would create another layer between the patient and providers of care,” Friedman said, noting that doctors would need to negotiate directly with hospitals for payment, rather than with insurance companies…

Instead, doctors and hospitals want an independent arbitrator to examine the amount the doctor is charging and what the insurer is agreeing to pay – and then determine which one is fairer…

But insurers are opposed to arbitration, and they’re pushing for Congress to set reimbursement rates.

In a letter to House and Senate leaders in March, America’s Health Insurance Plans urged lawmakers to “avoid the use of complex, costly and opaque arbitration processes that can keep consumers in the middle and lead to higher premiums.”

The White House also threw cold water on arbitration. During a briefing with reporters on Thursday, administration officials called arbitration an “unnecessary distraction.”..

“Providers point fingers at payers, payers point fingers at providers, and the American people are left really getting the shaft,” a senior administration official said.

The White House and lawmakers have been warning all the players to solve the problem on their own. But now with pressure from the White House, Congress is likely to act.

“There will come a point in time when they want to move a solution forward,” AHA’s Smith said. “It’s unlikely you’ll come to a solution where every one of the stakeholders is happy.”” (H)

“One of the major drivers of surprise bills is the deliberate decision by health insurance plans to narrow the networks of providers available to their insureds-core network adequacy requirements should be an essential component of any solution,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letters to committee leaders. “Shrinking networks increase the likelihood that patients may receive care from an out-of-network provider, particularly in emergency situations.”

..Patients are shouldering more of the costs through larger deductibles and higher copays. The median out-of-network deductible for individual marketplace is $12,000 and almost a third of individual market plans have deductibles of more than $20,000 according to research by the Robert Wood Johnson Foundation cited in the letter.

“Limited networks of providers and unaffordable deductibles for care outside those networks can expose patients to high out-of-pocket costs,” Dr. Madara wrote.

..Often insurance companies will use tactics such as prior authorization or “fail-first” step therapy protocols to make patients pay out of pocket for medically necessary treatment they refuse to cover.

.. Despite federal mental health-parity requirements, patients can feel squeezed by their health plans when it comes to mental health and substance-use disorder treatments-and that leads to a greater reliance on out-of-network care…

..Some insurance companies have enacted policies of not paying for emergency care after it was determined that patients did not require it-even though the severity of their symptoms at the time made it prudent to go to the nearest emergency department.

..Insurance companies often change their drug formularies after patients are locked into their plan. This can lead to restricting access to treatment that has proven to work for them and has stabilized their condition. Patients may seek to pay out of pocket to continue their treatment rather than jump through their insurance company’s prior-authorization hoops.” (I)

“Surprise medical bills exist for a number of reasons, each of which are specifically rooted in problems inherent to a privatized, profit-driven health-care system. For one thing, there wouldn’t be out-of-network bills without networks themselves-a health insurance innovation put forward in the 1980s. Unlike more regulated health-care systems in peer nations, the American health-care system lacks a robust mechanism to control prices. This leaves each insurance plan to negotiate with providers on its own, and gives the latter more power to set prices.

Once health-care prices began to skyrocket in the 1970s, insurance companies began to try several cost-cutting measures that are now all too familiar to modern policyholders…The theory behind networks was simple enough: By contracting only with certain providers, insurers could deliver a higher volume of patients to each one and thereby gain more leverage over pricing negotiations. They could then translate the savings into lower premiums, attract more customers, and increase market share…

..and it’s the same problem underlying the proliferation of varied “insurance products” that cater to different types of patients. The degree of “choice” a given person has is overwhelmingly determined by their income and health status, which is a shamefully unjust way to allocate the costs of running a health-care system. The healthiest people are able to take their chances on a narrow network, while those with greater health-care needs are financially penalized for needing a wider breadth of providers. Meanwhile, the less money someone has available, the more they’re coerced into “choosing” a plan based on price rather than benefits…

Discussing and tackling the inequities-and potential for financial ruin-in our health-care financing system demands an acknowledgment that the sheer diversity of insurance plans in this country, each with their own pricing and benefit structures, is an inherently bad thing. When it comes to insurance policies, a multitude of consumer choices translates into genuine differences in the ability to access care. “Surprise out-of-network bills” are one highly visible example of how that hurts people. Others are never hard to find.” (J)

“While President Donald Trump prods Congress to limit surprise billing, at least three states are debating legislation to ban the practice…

Current state laws vary in scale and effectiveness. Federal legislation would be more effective, as it would protect the millions who receive self-funded coverage through their employer. But the political climate in Washington, where even historically bipartisan efforts move slowly at best, has left states to step in and do what they can…

The Colorado General Assembly passed a bill earlier this month that prohibits surprise billing and sets a reimbursement rate based on either commercial claims data or the insurers’ median in-network rate for the service. Gov. Jared Polis, a Democratic, is expected to sign the bill Tuesday, a spokesman told Healthcare Dive.

A surprise billing law is also on the governor’s desk In Washington. It calls for a “commercial reasonable amount” to be paid to out-of-network providers and establishes arbitration if the parties cannot agree on a rate through negotiation.

In Texas, a bill has passed the Senate and is currently making its way through the House. It requires an arbitration process for payments that do not include patient involvement. Previous legislation in the state required people receiving surprise bills to request remediation…

The Employee Retirement Income Security Act of 1974 limits the effectiveness of state surprise billing legislation because state laws can’t apply to employer self-funded plans, which cover the majority of Americans. Still, the laws can serve a few key purposes.

Several of the bills proposed in Congress defer to state laws on issues like rate setting or arbitration. So even if Washington passes a ban on surprise billing, states that want to set their own plans can count on using their own laws going forward…

“States have a lot of authority over providers … just making sure the providers have posted information and are being as informative as possible when consumers are coming into their facilities,” she said.” (K)

Arizona’s new law on surprise medical bills went into effect January 1. It sets up a procedure where patients can request dispute resolution through the state’s Department of Insurance. Unresolved disputes will enter arbitration. If an enrollee participates in an informal settlement teleconference (IST) beforehand, the law spells out what an enrollee’s liability: “By virtue of having participated in the IST, the enrollee can only be held responsible for paying the amount of the enrollee’s cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.” (L)

“Consumer complaints about surprise medical bills have fallen substantially in New York in the wake of a 2014 law that established a “baseball-style” arbitration protocol to address these situations, according to a new report.

Researchers at the Georgetown University Center on Health Insurance Reforms (CHIR) conducted a case study (PDF) on the state’s Emergency Services and Balance Billing Law and found that state officials report a “dramatic” decline in consumer reports about balance bills since the law took effect in 2015.

Based on an analysis of calls to the Consumer Service Society’s helpline for surprise billing, 57% of complaints were handled using the systems established under the law.

“It’s downgraded the issue from one of the biggest

[consumer complaints our call center receives]

to barely an issue,” a state regulator told the CHIR researchers.

In addition to surveying state officials, the Georgetown researchers also interviewed physicians, insurers and patients, and they found that overall the participants view the arbitration process as fair. However, providers were more enthusiastic than insurers, according to the study.

As of October, the number of resolutions in favor of insurers and in favor of physicians is about even, according to the study-618 were decided in favor of payers and 561 in favor of providers.

Insurers were more likely to win disputes over out-of-network emergency care billing, while providers were more likely to win in situations where a patient is treated by an out-of-network physician without his or her knowledge during an elective procedure.” (M)

“The American Hospital Association was among six national hospital groups that sent a letter to Congress on Wednesday to suggest parameters and ideas that legislators should keep in mind as they pursue a solution to surprise medical bills…

The letter to Congress, a copy of which was obtained by ROI-NJ, asks federal representatives to consider:

Defining what is considered a surprise bill;

Ensuring patients are protected and not balance billed;

Ensuring patients are not denied emergency coverage if a visit is considered non-emergent in retrospect;

Avoiding setting a fixed payment rate;

Ensuring patients are educated about their rights and coverage;

Supporting state laws (like those in New Jersey) that are protecting consumers.” (N)

“Assemblyman Nick Chiaravalloti is planning to introduce legislation in May that would plug a loophole in the (New Jersey) out-of-network law that has been affecting patients transferred out of state…

Health care professionals would be required to document in the patient records and notify patients of

The patient’s right to receive care at a facility of choice;

Clinical rationale for the out-of-state transfer;

Location of the out-of-state facility;

Availability of clinically appropriate services at nearby New Jersey facilities;

The nature of the relationship if the patient is being transferred or referred to an affiliated facility; and

In instances of trauma, stroke or cardiovascular diagnoses, an explanation as to why the patient is not being transferred to a facility in New Jersey.

The bill also requires patients be provided information from their insurance providers as to their potential out-of-pocket costs for an out-of-state facility, and requires health facilities to disclose to patients their relationships with out-of-state providers the patients are being referred to.

This is particularly important with the recent merger activity in South Jersey with some hospitals tied to health systems in Pennsylvania…

“To ensure that health care consumers are able to make well-informed health care decisions, patients should be informed of their right to select the facility in which they receive their care before being transferred to another state,” he said. “Patients should have all the information about why they are being transferred, and their financial responsibilities associated with the transfer – only then can a patient make an informed choice.” (O)

“One of the many wonderful advantages we have as residents of New Jersey is access to high quality, advanced health care. In fact, more than half of New Jersey’s 67 acute-care hospitals received an “A” rating in the Leapfrog Hospital Safety Report, the highest percentage of “A” ratings in any state across the nation. New Jersey is also home to tremendously skilled physicians and nurses, as well as 13 academic health systems training the next generation of health care professionals and researchers. Clearly, New Jersey residents have access to some of the nation’s greatest health care resources.

Despite these facts, a significant number of patients are referred or transferred to health care providers and hospitals located out of state. Some estimates indicate that New Jersey residents spend more than $2 billion annually on health care services out of state. Often these patients are paying considerably more for their out-of-state health care and receiving care that is equal to or less effective than they could have received at hospitals in New Jersey. With health care consumers paying a larger percentage of their health care costs through higher deductibles, copayments, and coinsurance, paying more for the same quality of care further from home makes little sense.

New Jersey residents should have the right to obtain health care wherever they believe it is best, but often patients do not have critical information necessary to make an informed decision. Moreover, many New Jersey residents do not understand the strong consumer protections they are forfeiting by seeking care outside of the state.” (P)

“Bob Ensor didn’t see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor’s nose, the physicians realigned his facial bones, temporarily sewing Ensor’s left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor’s company health plan had denied payment because the surgeon wasn’t part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn’t cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

“The hospital knew these doctors were out-of-network and didn’t bother to tell us,” said his wife, Linda Ensor, noting they faced more than $167,000 in charges. “We were panicked.”

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it “empathizes with patients who are trying to navigate the complexity of the health care billing system” and that transparency in billing has not always been optimal for emergency department patients…

Many plastic surgeons don’t participate in health plans because they have flexibility other physicians may not have – their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own…

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club’s insurer agreed to cover the accident as a workers’ compensation case. It paid 100% of the outstanding bill.” (Q)

“In an email to a complaining patient, the CEO of Spectrum Health acknowledged there needs to be more transparency regarding how patients are billed for doctor visits.

“We agree with you that a more transparent process is necessary,” Spectrum Health CEO Tina Freese Decker wrote (PDF) in response to a complaint. “I have shared your suggestion (for additional transparency) with our Spectrum Health Medical Group leadership so that we can apply this suggestion into our workflow.”..

The patient who sent the email to the CEO – and shared the response with Target 8 – had been charged $142 for a second appointment because she briefly discussed two minor issues with her doctor during her annual exam…

A month later, the patient received her bill. The annual wellness visit was covered by insurance, but there was a second charge for the same day that was not covered…

Additionally, a single mother from a small town in Kent County, who Target 8 is identifying only as Lindsey, previously reached out to Target 8 regarding a bill she got after a wellness visit with a physician at Spectrum medical building in Grand Rapids. While she waited for the appointment, Lindsey filled out the standard questionnaire, checking a box to indicate she had periodic leg cramps.

“(The doctor) looked at the form and she said, ‘Oh, I see you checked yes to leg cramps. Tell me more about it,'” Lindsey recalled.

Lindsey said the doctor showed her some stretches, told her to drink more water and checked her magnesium and iron levels in addition to the routine blood tests that were already scheduled for her annual physical.

“I get the bill… and I was charged for two office visits,” Lindsey said in an interview with Target 8 Thursday. “I called the doctor’s office right away and I said, ‘This can’t be right. Is this a mistake?'”

But it wasn’t a mistake…

If you’re going in for preventive services, know that there is a scope of services that’s considered preventive with zero cost, but if you go in and have a complaint or a scenario diagnosed, then it changes… to another category of care,” “.. (R)

“Yale researchers Zack Cooper and Fiona Scott Morton looked at emergency department visits that occurred at hospitals that were in insurers’ networks, in a paper for the New England Journal of Medicine. “On average,” they found, “in-network emergency-physician claims were paid at 297% of Medicare rates,” while “out-of-network emergency physicians [within in-network hospitals] charged an average of 798% of Medicare rates.”

A study from UnitedHealthGroup, looking at its own claims nationwide, recently estimated that out-of-network emergency physicians increased health care charges by $6 billion per year.” (S)

What’s behind this explosion of outrageous charges and surprise medical bills? Physicians’ groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians’ practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms…

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies – EmCare and TeamHealth – took over hospital ERs. They found:

“…that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.”

TeamHealth used the threat of sending high out-of-network bills to the insurance company’s covered patients to gain high fees as in-network doctors. The researchers found:

“…in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.”

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines. (T)

  1. A.Surprise medical bills: The doctor is not in your insurance plan, by Liz Kowalczyk,
  2. B.Remarks by President Trump on Ending Surprise Medical Billing,
  3. C.Trump: Hospitals, payers must be held accountable for surprise medical bills, by Chris Mazzolini,
  4. D.Exclusive: the new bipartisan House bill to stop surprise medical bills, explained, by Dylan Scott,
  5. E.Analyzing The House E&C Committee’s Bipartisan Surprise Out-Of-Network Billing Proposal, byLoren Adler Paul B. Ginsburg Mark Hall Erin Trish,
  6. F.Senate working group releases surprise medical bills legislation, by DAN DIAMOND,
  7. G.Dueling surprise bill measures were introduced on Capitol Hill. Here’s where they differ, by by Paige Minemyer,
  8. H.Health industry to clash over surprise medical bills, by NATHANIEL WEIXEL,
  9. I. 6 ways insurers drive the surprise-billing phenomenon, by Andis Robeznieks,
  11. K.As Trump wades in, states move on surprise billing, by Shannon Muchmore,
  13. M.New York’s arbitration program for surprise billing leads to decline in consumer complaints: study, by Paige Minemyer,
  14. N.NJ. law on surprise medical bills could help shape similar federal legislation, by Anjalee Khemlani,
  15. O.Out of state, not out of mind: Bill would close out-of-network loophole, by Anjalee Khemlani,
  16. P.3 hospital CEOs say patients should be told about their health care options before being transferred out of state, by Robert Garrett, Brian Gragnolati and Barry Ostrowsky,
  17. Q.Putting A Face To Surprise Bills: Among Specialists, Plastic Surgeons Most Often Out-Of-Network,
  18. R.Spectrum CEO: More transparency needed in billing, by Susan Samples,
  19. S.How To End The Scourge Of Surprise Medical Bills In The Emergency Room, by Avik Roy,
  20. T.Private Equity is a Driving Force Behind Devious Surprise Billings, by EILEEN APPELBAUM,

PART 3. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because she did not know when a new heart would become available.

“On March 8, 2011, Joclyn Krevat, an occupational therapist in New York, was sitting at her computer when she received a most unusual LinkedIn request. The wording was the familiar: “I’d like to add you to my professional network.” The sender was familiar, too, but not for the reason Krevat expected. It was from a debt collector.

Karen Pollack, the head of a debt-collections practice called KP Recovery Solutions, had been trying to collect on some medical bills Krevat had recently incurred for a heart transplant. Krevat’s debts, which were reviewed by The Atlantic, made up plot points in the worst kind of American health-care horror story. In December 2009, Krevat, who was 32 at the time, thought she was coming down with the flu. Instead, she was admitted to the hospital and diagnosed with giant cell myocarditis, a severe inflammatory heart disease that can lead to heart failure. After seven weeks on life support, a heart became available, and she had a transplant. For a year afterward, she wasn’t able to return to work.

Krevat’s husband was a teacher, and Krevat had good insurance through him. But some of the doctors who treated her turned out to be out-of-network-a situation she couldn’t control, because she did not know when a new heart would become available. She estimates that if she had paid every bill that was sent to her, the total would have been about $50,000…

Krevat’s bills began to arrive while she was still being treated at Columbia University Irving Medical Center. One came from one of the hospital’s doctors, Mathew R. Williams, for $9,000. Another came from a doctor named Aziz Ghaly for $17,418. A few months later, a separate invoice from Weill Cornell Physicians said she owed $22,464…

Krevat appealed to GHI, her insurer, saying the services should have been covered because she was unconscious when she received them. “I was never in a position to preselect who can perform my heart transplant,”… (A)

“From a planning perspective, Wolfgang Balzer is the perfect health care consumer.

Balzer, an engineer, knew for several years he had a hernia that would need to be repaired, but it wasn’t an emergency, so he waited until the time was right.

The opportunity came in 2018 after his wife, Farren, had given birth to their second child in February. The couple had met their deductible early in the year and figured that would minimize out-of-pocket payments for Wolfgang’s surgery.

Before scheduling it, he called the hospital, the surgeon and the anesthesiologist to get estimates for how much the procedure would cost.

“We tried our best to weigh out our plan and figure out what the numbers were,” Wolfgang said.

The hospital told him that the normal billed rate was $10,333.16 but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon’s office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his copayment would be about $94. (Although the Balzers made four calls to the anesthesiologist’s office to get a quote, leaving voicemail, no one returned their calls.)

Estimates in hand, they budgeted for the money they would have to pay. Wolfgang proceeded with the surgery in November, and, medically, it went according to plan.

Then the bill came.

The bill for Wolfgang’s surgery turned out to be $2,304.51, $800 higher than he and his wife, Farren, had budgeted for, based on the estimates. “That’s a huge hit,” Farren says.

Total Bill: The estimates the Balzers had painstakingly obtained were wildly off. The hospital’s bill was $16,314. After the insurer’s contracted discount was applied, the bill fell to $10,552, still 51% over the initial estimate. The contracted rate for the surgeon’s fee was $968, more than double the estimate. After Cigna’s payments, the Balzers were billed $2,304.51, much more than they’d budgeted for…

When the bill came on Christmas Eve, the Balzers called around, trying to figure out what went wrong with the initial estimate, only to get bounced from the hospital’s billing office to patient accounts and finally ending up speaking with the hospital’s “Integrity Department.”

They were told “a quote is only a quote and doesn’t take into consideration complications.” The Balzers pointed out there had been no complications in the outpatient procedure; Wolfgang went home the same day, a few hours after he woke up.

The couple appealed the bill. They called their insurer. They waited for collection notices to roll in.

Hospital estimates are often inaccurate and there is no legal obligation that they be correct, or even be issued in good faith. It’s not so in other industries. When you take out a mortgage, for instance, the lender’s estimate of origination charges has to be accurate by law; even closing fees – incurred many months later – cannot exceed the initial estimate by more than 10%. In construction or home remodeling, while estimates are not legal contracts, failure to live up to them can be a basis for liability or “a claim for negligent misrepresentation.”..

Efforts to make health care prices more transparent have not managed to bring down bills because the different charges and prices given are so often inscrutable or unreliable, said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School…

The Takeaway: It is a good idea to get an estimate in advance for health care if your condition is not an emergency. But it is important to know that an estimate can be way off – and your provider probably is not legally required to honor it.

Try to request an estimate that is “all-in” – including the entire set of services associated with your procedure or admission. If it’s not all-inclusive, the hospital should make clear which services are not being counted.

Having an estimate means you can make an argument with your provider and insurer that you shouldn’t be charged more than you expected. It could work.

Laws requiring some degree of accuracy in medical estimates would help. In a number of other countries, patients are entitled to accurate estimates if they are paying out-of-pocket…(B)

“It appears that out-of-network billing for inpatient admissions and emergency department (ED) visits is becoming more common and expensive for patients.

Publishing in JAMA Network, study researchers examined 5.4 million inpatient admissions and 13.6 million ED visits between 2010 and 2016 and found that more than 39% of ED visits generated an out-of-network bill and 37% of all inpatient admissions resulted in an out-of-network bill.

The analysis of the claims data for privately insured patient showed an increase from 32.3% to 42.8% of ED out-of-network bills during the time period.

The study, led by Eric Sun, M.D., assistant professor in the Department of Anesthesiology, Pain and Perioperative Medicine at Stanford University, also found an increase from 26.3% to 42% of inpatient admissions with out-of-network bills.

Overall, the changes resulted in an increase from around $220 to $628 for an average ED patient visit for those with private insurance and an average increase from $804 to $2,040 for inpatient admissions costs.

Out-of-network billing for ED visits was particularly common for ambulance transport: 85.6% of encounters with ambulance services resulted in an out-of-network bill, with a mean potential financial responsibility of $244 to the patient.

Of patients receiving care from an emergency physician, 32.6% received an out-of-network bill while 23.8% of patients received an out-of-network bill from care from an internist and 22.8% received an out-of-network bill from care from an anesthesiologist.

When it comes to inpatient admissions, physician specialties with the most frequent out-of-network billing ranged from 0.8% for obstetrics and gynecology to 81.6% for ambulance services…

As of June, 25 states have enacted legislation offering some protection against out-of-network billing, ranging from dispute resolution processes to provisions holding the insurer responsible for the balance-billed amount.

In the U.S. Congress, pending legislation could help limit the scope and effects of out-of-network billing.

“Because out-of-network bills most commonly originated from clinical services (ie, medical transport, emergency medicine) about which patients have little choice, policy solutions centered on disclosure and consent at the point of care may not meaningfully address a large part of the problems patients face,” the authors said in the report. “Policies that limit the ability of physicians and medical transport services to balance bill patients-for example, by shifting some portion of the patient’s responsibility to insurers-offer stronger protection.” (C)

“Few defend the practice of surprise billing. Study authors note the ability to receive care from an out-of-network doctor could in theory provide flexibility for patients, but that doesn’t hold up when the patient isn’t aware a doctor treating them isn’t in network – providing the “surprise” aspect.

Out of network billing “appears to have become common,” according to the study author, noting the average amount of these bills is “sufficiently large that they may create financial strain for a substantial proportion of patients.”

The new research adds to the growing evidence surprise billing is becoming more prevalent. The Trump administration backs legislation to ban the practice, and several proposals are making their way through Congress, but there isn’t yet a concrete path. Lawmakers in Washington won’t pick up the issue again until after the summer recess at the earliest.

In an editorial accompanying the study, JAMA Internal Medicine Editor at Large Robert Steinbrook called on lawmakers to take action. “Congress and the Trump administration have the opportunity to solve the problem of surprise medical bills and move on to more far-reaching reforms to improve U.S. health care and decrease its costs,” he wrote.

Provider and payer lobbyists have been pushing back against the various efforts. Hospital and doctor organizations have railed against proposals, such as the main Senate HELP committee draft, which sets a payment standard for out-of-network services…

Other research has shown the pervasive effects of surprise billing. A Health Care Cost Institute report from March found that 15% of in-network hospital admissions had at least one out-of-network professional claim, with varying levels by specialty and location.

A USC-Brookings Schaeffer Initiative for Health Policy analysis showed about 20% of ER visits involved an out-of-network provider, and the Kaiser Family Foundation has found about 40% of Americans have reported receiving an unexpected medical bill.” (D)

“Surprise out-of-network bills arise when people turn to a hospital they know is part of their insurance plan’s network, but are treated by a doctor or provider in the hospital who does not have a contract with the insurer.

“In-network” providers agree to set rates with insurers and are not allowed to bill patients for more than their share of that contracted rate.

Providers who do not have contracts with insurers are considered out-of-network and can bill patients directly for the full cost of the service.

Medicare limits this practice, called balance billing. At least 25 states, including New Jersey, have established their own rules to protect privately insured patients. Other states and federal lawmakers are also considering legislation.” (E)

“Essentially no one in the United States likes surprise medical bills. That’s why Democratic and Republican leaders in both the House and the Senate pulled together common-sense bills earlier this year to curtail the practice.

So why isn’t such legislation a slam dunk? Because special interests – specifically hospitals and the private-equity-backed companies that have largely taken over their emergency rooms – are standing in the way. As lawmakers return to session next week, they should make it a priority to end this abusive tactic.

Studies suggest that surprise billing occurs in 20 percent of emergency-room visits – though the rate could be as high as 42 percent. The practice often happens when certain physicians at a hospital – for example, radiologists or anesthesiologists – issue a separate bill because they do not have a contract with the patients’ insurer regarding charges for specific services, even though the hospital is in network.

Imagine, as my colleague Benjamin Chartock puts it, going to a restaurant and getting a separate, unexpected bill for dessert because the pastry chef did not sign a contract with the owner. Such is the case when patients go to the hospital, where they are “captured” and don’t have the option to choose an in-network physician or to go without health care. This dramatically enhances the bargaining power of those physicians; without a contract, they can charge the infamous chargemaster prices that hospitals assure only foreign billionaires pay.

Frankly, however, doctors are not conniving enough to have figured out this scheme, nor are they responsible for putting it on an industrial scale. Surprise medical bills are the doing of the financial sorcerers at companies such as EmCare and TeamHealth, both owned by private equity firms, which are responsible for outsourced emergency rooms in hundreds of hospitals across the country.

Yale University researchers have found that when these companies take over an emergency room, the frequency of surprise billing skyrockets. For instance, EmCare takeovers of ERs caused a jump in surprise billing by almost 82 percentage points. And when TeamHealth employs the physicians, the frequency of surprise billing increased by 33 percentage points. (After the Yale study was published, EmCare negotiated with insurers to counter the torrent of negative press.)

The legislation making its way through Congress attempts to solve this by getting patients out of the middle, protecting them by charging them no more than typical in-network co-pays. The bills would also establish a fair price for the physicians who are out-of-network. The benchmark price, which would rise with inflation, would be the median in-network rate for the service in the local market where the patient was seen. That means physicians who do not sign contracts with insurers – in hopes of hitting the jackpot with out-of-network patients – would be paid the same as other similar physicians who were not so greedy.

The House – but so far not the Senate – has also proposed an appeals and independent arbitration process if physicians and hospitals are not happy with the benchmark payment. This is a sop to physicians, but it hasn’t kept special interests from spending millions of dollars on lobbying and political ads that target congressional members and portray physicians as poor victims of rapacious insurance companies.

Their complaints are hard to take seriously. Radiologists, anesthesiologists and emergency-room physicians are paid very well. Private insurers on average pay anesthesiologists about 3.5 times what Medicare pays, even while other physicians get on average only 1.3 times Medicare rates from private insurance. The average salary for radiologists is nearly $420,000 per year and for anesthesiologists is almost $390,000.

Hospitals fear, too, that they would be paid less under such legislation. They routinely warn that without the higher payments, they would have to reduce services or even close. But extorting patients with surprise bills hardly seems the way to shore up hospitals’ finances…

It appears that despite the overwhelming public interest, the usual will happen: Congress will waver and fail to pass a bill. Though Senate Majority Leader Mitch McConnell (R-Ky.) has expressed support for a bill in the past, there’s no guarantee he will allow the bill to come to the Senate floor.

If Congress fails to stand up to special interests here, what hope is there for legislation that addresses bigger health-care issues, such as exorbitant drug prices? It is enough to make believers in representative democracy scream in disgust.

No one likes surprise medical bills. So why does congressional action seem so unlikely?, (F)

“There is a broad consensus that consumers should be held harmless when they — through no fault of their own — receive bills from physicians that turn out to be out of network even though they work at in-network hospitals, she said. However, “the broad question is what the provider who’s provided those services will get reimbursed.” Two congressional committees — the Senate Health, Education, Labor, & Pensions (HELP) Committee and the House Energy & Commerce Committee — have already marked up their versions of surprise billing legislation, but two other House committees — Education & Labor and Ways & Means — have yet to produce bills; the issue will be how all those bills are reconciled with one another, Fontenot said.

“One thing that’s interesting to note is that the HELP Committee’s proposal did score a fairly significant level of savings, which they then used to reauthorize some of the public health programs in their jurisdiction,” she added. “As you change that proposal, as it goes through the process … those savings will dissipate depending on what they’re replaced with.” (G)

“Several states have created regulation that protects patients from the high medical care bills-but their authority only goes so far.

State bills cover the largest insured population-state employees-and commercially insured plans. But they do not regulate self-insured plans, often the plans used by large employers or companies who group purchase health care through a trade association. Those fall under federal law and make up more than 60 percent of health insurance plans in the country.

The regulations in each state typically differ in how they resolve the difference in what the provider claims and what they are reimbursed by the insurer.

In New York and Connecticut, for example, the states chose to pursue independent reviews, but are using cost information provided by a database, from FAIR Health, as the benchmark.

In New Jersey, meanwhile, the state chose to use baseball style arbitration-where both the health provider and the insurer provide their offer to a third-party arbitrator, and only one of the two final offers is chosen.

Despite the efforts at the state level, many patients still see high surprise bills because no federal regulations exist.

While regulating the industry is sought to be a political and policy win, both sides have their concerns.

The relationships between providers and insurers is already contentious-both are often on opposite sides of the table with insurers trying to negotiate down rates while providers are trying to negotiate increases in rates.

Both sides have said in state hearings around the country that the regulations will interfere in this delicate dance.

Neither disagree that there should be a provision stating that patients should be held harmless, but both want the government to stay away from the rest of the process.

The American Hospital Association voiced a similar concern Wednesday after the passing of the House committee bill.

“The AHA believes that once the patient is protected from surprise bills, providers and insurers then should be permitted to negotiate payment rates for services provided,” said executive Vice President Thomas Nickels in a statement.

“We strongly oppose approaches that would impose arbitrary rates on providers. It is the insurers’ responsibility to maintain comprehensive provider networks, and a default payment rate would remove incentives for plans to contract with providers or to offer fair terms.”

Similarly, the insurance lobbying group, America’s Health Insurance Plans, voiced concern.

“We strongly oppose the inclusion of arbitration because it does not solve the problem of surprise medical bills,” said AHIP president and CEO Matt Eyles.

“It increases the financial burden on everyone with coverage, increasing patient premiums and driving up the cost of health care. The arbitration proposal allows private-equity firms and certain providers to price gouge patients and then shifts the final decision to a ‘third party.’ This process introduces new bureaucracy and red tape into the system, with costs to hardworking taxpayers exceeding $1 billion.”

The Congressional Budget Office estimated that enacting the surprise medical billing law would reduce the deficit by almost $25 billion from 2019-2029.” (H)

“The Congressional Budget Office estimates a Senate package tackling surprise billing and drug prices will save the government $7 billion…

A majority of the increased federal revenue would come from the portion of the legislation that targets surprise medical bills. The legislation calls on insurers to pay a median in-network rate for out-of-network care for surprise bills. It would also ban balance billing, a practice where a provider bills the patient for any difference between the insurer payment and the provider’s charges.

CBO estimates that the surprise medical bill portion would increase revenue by $23.8 billion and reduce direct spending by $1.1 billion for total savings of $24.9 billion through 2029.

“That estimate accounts for effects on federal subsidies for insurance purchased through the marketplaces and for the effects that arise from lower premiums for employment-based insurance,” the CBO said.

The CBO says the strategy employed in the bill would carry some additional costs for insurers such as the cost of calculating the median in-network rates. Still, it says premiums would decline because the bill would require insurers to reimburse out-of-network providers through their own median rates for an in-network provider.” (I)

“The problem is, most of the solutions that are seriously being considered stand to hit providers and hospitals the hardest-particularly those that treat a high percentage of out-of-network patients, according to a new report from Moody’s Investors Service.

That includes hospitals, physician staffing companies and laboratories as well as radiology and other ancillary provider companies. Some of the proposals could also impact air ambulance providers.

For example, the bipartisan Lower Health Care Costs Act of 2019 from Senate Health Committee chairman Lamar Alexander and ranking Democrat Patty Murray would, among other things, require insurance companies to pay out-of-network doctors for care at a rate tied to the median in-network fee for treatments.

Likewise, providers would be barred from “balance billing,” or requiring patients to pay the difference between what their insurer is willing to pay and what the doctor says they’re owed. That legislation has been scheduled for markup next week.

“The solution that would have the least credit impact would be the arbitration avenue which is what certain states are already doing for state-regulated plans. It takes the patient out of the middle but preserves that kind of bargaining-negotiation between the provider and the insurer,” said Jessica Gladstone, an associate managing director at Moody’s and lead author on the report, told FierceHealthcare. (A Senate bill had been introduced last month proposing a “baseball-style” arbitration.)

According to the Moody’s, the proposals of capping out-of-network charges for emergency medical services at in-network levels, setting up an arbitration process to resolve out-of-network charges or requiring a single ‘bundled bill’ are all considered “credit negative.”

Of the potential options, bundled billing and in-network guarantees would be the most negative for hospitals and staffing companies. That is because many hospitals totally outsource the operations and billing of the emergency department to a staffing company.

“If you now require a bundled bill or an in-network guarantee, you’re now asking the hospital to control very large portions of the hospital operation that it had never had to control before. Most hospitals would outsource the emergency department precisely because they did not want to have to deal with the billing and the complexities that come with that,” Gladstone said. “That kind of proposal would fundamentally change the relationship between the hospital and the physician staffing companies.”

An in-network guarantee would add significant complexity, because many physicians and ancillary service providers are not employed or controlled by the hospital, she said.” (J)

“Two years, 16 hearings and one massive bipartisan package of legislation later, a key Senate committee says it is ready to start marking up a bill next week designed to contain health care costs. But it might not be easy since lawmakers and stakeholders at a final hearing Tuesday showed they are still far apart on one simple aspect of the proposal.

That sticking point: a formula for paying for surprise medical bills, those unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network.

“People get health insurance precisely so they won’t be surprised by health care bills,” said Sen. Maggie Hassan (D-N.H.), the co-author of a separate proposal to tamp down surprise bills. “So it is completely unacceptable that people do everything that they’re supposed to do to ensure that their care is in their insurance network and then still end up with large, unexpected bills from an out-of-network provider.”

It’s a cause that has been taken up by President Donald Trump and various bipartisan groups of lawmakers on Capitol Hill.

The wide-ranging legislative package on curbing health care costs is sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member of the Health, Education, Labor and Pensions (HELP) Committee. Given the committee’s influence, and because this legislation has bipartisan support in the Senate where not many bills are moving, industry observers are taking the HELP panel’s proposal very seriously.

Alexander and Murray’s bill lays out three options for paying surprise medical bills but does not specify which path the final legislation should take. Advocates for each of the choices were among the five witnesses Tuesday.

Their positions fell along familiar fault lines. Everyone acknowledged that patients who stumble into a surprise bill because their emergency care was handled at a facility not in their insurance network or because a doctor at their in-network hospital doesn’t take the patient’s plan should not have to pay more than they would for an in-patient service. But they differ on how much doctors, hospitals and other providers should be compensated and how the disputes should be resolved.

Tom Nickels, an executive vice president of the American Hospital Association, cautioned against using benchmarks to set pay levels, such as local customary averages or a price set in relation to Medicare. He said such a plan might underpay providers and hospitals could lose their leverage to negotiate with insurers.

Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health – a group that represents employers, including some who are self-insured who pay their workers’ health costs- said doctors should be paid 125% of what Medicare pays. She told senators that an independent arbitration process like the one Nickels advocates would add unnecessary costs to the system.

Benedic Ippolito, a researcher with the American Enterprise Institute, said requiring all providers in a hospital to be in-network was the cleanest solution.

“On surprise billing, all three approaches are equal in that first and foremost they protect the consumer,” said Sean Cavanaugh, chief administrative officer for Aledade, a company that matches primary care physicians with accountable care organizations.

There was also broad support among the witnesses for some of the legislation’s transparency measures, especially the creation of a nongovernmental nonprofit organization to collect claims data from private health plans, Medicare and some states to create what’s called an all-payer claims database. That could help policymakers better understand the true cost of care, these experts told the committee.

Sen. Susan Collins (R-Maine) expressed trepidation about the all-payer claims database, noting that increased transparency could hurt rural hospitals, which typically charge higher prices than those in cities because their patient base is small and they need to bring in enough revenue to cover fixed costs.

The witnesses also offered support for eliminating “gag clauses” between doctors and health plans. These stipulations often prevent providers from telling patients the cost of a procedure or service.

“Patients and families absolutely have skin in the game … but they are in a completely untenable and unfair situation. They have no information,” said Mitchell, from the Pacific Business Group on Health. “We’re talking about providers not being allowed to share information. … Transparency is necessary so people can have active involvement.”

If one thing is clear, it’s that Alexander doesn’t want this summer to be a rehash of last year, when it appeared he had a bipartisan deal to address problems in the federal health law’s marketplaces before the effort fell apart.

“For the last decade, Congress had been locked in an argument about the individual health care market,” said Alexander at Tuesday’s hearing. “That is not this discussion. This is a different discussion. We’ll never lower the cost of health insurance until we lower the cost of health care.” (K)

“A shadowy group has spent more than $13 million since July advertising in states with vulnerable senators to oppose legislation that would rein in medical bills that take patients by surprise.

The campaign by a group calling itself Doctor Patient Unity, playing out on television, radio, and on social media in more than 20 states, is helping muddy the congressional debate over how to combat surprise medical bills and could make it harder to pass legislation this year, congressional aides familiar with the issue said in interviews, speaking on condition of anonymity.

The ad buys represent the most-expensive campaign on any health-related topic Congress has taken on this year, according to data from Advertising Analytics and Federal Communications Commission filings. That they’re targeting lawmakers up for re-election in 2020 sends the message that deep-pocketed interests are paying attention to how lawmakers vote on the issue.

“Ads like these with large budgets behind them effectively serve as a warning that even more money could be used to unseat the legislator if they vote the opposite way,” said Erika Franklin Fowler, who directs the Wesleyan Media Project, which tracks and analyzes political advertising in real time during elections.

The group has made seven-figure advertising purchases in seven states and six-figure buys in six more states. They all warn against “rate setting” and the group’s website urges listeners to contact lawmakers to oppose “stand up to the insurance industry and demand they pay for their fair share.”

Who is ultimately paying for these ads is shrouded in secrecy. The television ads are known as “issue ads” and therefore don’t require Federal Election Commission disclosure.

The ads are all being bought either by Del Cielo Media of Alexandria, Va., or its parent company, Smart Media Group, also of Alexandria, according to FCC filings. Both companies didn’t return repeated messages seeking comment.

Del Cielo has been linked to Republican campaigns. The group bought ads for political action committees opposing Democratic candidates such as Phil Bredesen, the former Tennessee governor who lost a Senate bid to Republican Marsha Blackburn in 2018, according to FCC filings. Del Cielo got more than $1.2 million from a political action committee favoring President Donald Trump, according to filings with the Federal Election Commission.

Doctor Patient Unity was formed as a corporation in Virginia by a limited liability company with the same address as the firm Holtzman Vogel Josefiak Torchinsky, according to state business filings. The law firm provides “strategic counsel and compliance advice” to entities involved in political and policy affairs, according to its website.

By using middlemen such as media buyers and corporation creators, the entities funding the ads can conceal their identities.

“One of the issues with the ‘dark money’ groups is that, by design, the identity of donors are intended to remain hidden,” said Anna Massoglia, a researcher at the Center for Responsive Politics.

The ads come amid a flurry of activity on surprise medical billing. House and Senate committees have approved legislation to ban what’s known as balance billing, where a provider seeks payments directly from patients for charges their insurers won’t cover.

Both the House and Senate bills, H.R. 3630 and S. 1895, would require health-care providers in certain emergency circumstances to accept a set rate, based on median rates for those services, when they treat patients as out-of-network providers.

Some senators, including some of those targeted by Doctor Patient Unity such as David Perdue (R-Ga.), have backed surprise medical billing legislation (S. 153) that takes a different approach, empowering a third-party arbitrator to settle billing disputes. While the group’s purpose in targeting a lawmaker who opposes rate-setting isn’t clear, it’s a matter subject to change in any compromise measure.

Sen. Thom Tillis (R-N.C.) in a statement said he’ll work to “improve and finalize” the Senate’s surprise medical billing legislation. His office didn’t respond to a request to clarify whether he supports the arbitration or rate-setting approach.

Doctor Patient Unity spent more than $300,000 Aug. 23 on ads that appear to target Sen. Jeanne Shaheen (D-N.H.), a potentially vulnerable Democrat, according to FCC filings. The two purchases of ad time are both in stations in Manchester, N.H.

Shaheen hasn’t been outspoken about surprise medical billings this year, but in 2018 introduced a bill (S. 3541) that would have tackled the same issue by capping the amount that hospitals and physicians could bill with out-of-network charges to people with individual market coverage.

According to FCC filings published Aug. 26, Doctor Patient Unity also bought nearly $5,000 in additional ads to air in the last weeks of August in nearby Maine, where Sen. Susan Collins (R-Maine) also faces a tough re-election bid.

Health-care provider and hospital groups have also pushed back on the rate-setting approach, claiming it unfairly favors insurers and warning it could discourage doctors from practicing in certain areas where the rates would be lowest. These groups have spent heavily to influence the bills this year.

The American Hospital Association has spent almost $10.2 million on lobbying in the first half of 2019, about $1 million more than at the same time in 2018, according to congressional filings. The American Medical Association likewise shelled out $11.5 million on lobbying in the first half of 2019, about a $1 million more than at the same point in 2018.

Health-care providers, particularly specialists, have a lot of money at stake. The Senate version would cut enough costs from the health-care industry to lower insurance premiums nationwide by about 1%, the Congressional Budget Office estimates.

Some lawmakers worry that private companies with lots of capital, such as private equity firms that own health-care provider staffing groups, could be putting their money into opposing the surprise billing legislation.

The private equity firm KKR bought Envision Healthcare, a hospital-based physician group, in 2018 for about $10 billion and Blackstone Group bought TeamHealth, another hospital-based physician group, for $6.1 billion in 2016.

Yale University health economists in 2018 looked at two emergency room outsourcing companies, EmCare and TeamHealth, and found they took advantage of an environment where they could either charge high out-of-network rates to patients or negotiate higher in-network rates with insurers.” (L)

“Lawmakers are returning to work Monday to a simmering fight over how to handle surprise medical bills, with the provider industry having spent the summer pushing hard for major changes.

Provider groups have spent the monthlong August congressional recess heavily lobbying lawmakers and their staff to use an arbitration model to resolve out-of-network payment disputes instead of a benchmark rate.

A legislative package passed by the House Energy and Commerce Committee has a benchmark rate for any out-of-network charges, but with a backstop that allows both providers and insurers to head to arbitration if negotiations break down. The Senate Health, Education, Labor and Pensions (HELP) Committee passed legislation in June that used a benchmark rate.

However, neither package has gotten a vote in the full House or Senate yet.

The Energy and Commerce legislation is right now in a “holding pattern” before reaching the House floor as both the House Education and Labor Committee and the Ways and Means Committee are considering their own surprise billing legislation, a House aide told FierceHealthcare. Meanwhile, in the Senate, Republican Sen. Bill Cassidy of Louisiana and Democrat Maggie Hassan of New Hampshire have their own legislation that includes an arbitration provision.

Some provider groups are aiming to influence whatever comes out of the two House committees.”..(M)

Thankfully, a few extra steps and simple strategies can be made to ensure you don’t get any more unexpected medical bills in the future. Here’s how you go about it:

Learning is half the battle –

Always stay in-network –

Keep asking – Always, always ask about coverage –

Get some preauthorization –

Always plan ahead –

Compare costs –

Document everything – (N)

N.Unexpected Health Bills: Tips To Avoid Them, by Jan Cortes,

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RAPID RESPONSE. Hurricane Dorian – Hospital Preparedness

ASSIGNMENT: You are the CEO of a hospital in the cone of Hurricane Dorian! Tomorrow morning you have an 8AM Board of Trustees Conference Call to brief Board members on your hospital’s Rapid Response plan.

Starting with the sources below prepare your 15 minute presentation!


We don’t know what we don’t know” The challenge to emergency preparedness…..

Project Management. The hardest part of getting started….is getting started

“…the only respond to a crisis to ensure every member of the staff feels as though they are part of a team.” (Hurricanes, Mass Disasters, Wild Fires)

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)


Hospital disaster preparedness: best practices learned from Hurricane Irma

Hurricane Season Ready: Preparedness and Response Resources

Agency for Health Care Administration.  Health Care Facility Updates

Hurricane Preparedness in New York State

5 lessons all cities can learn from Hurricane Katrina

Lessons learned from Hurricane Sandy


Hospitals gather supplies, prepare staff as Hurricane Dorian approaches Florida coast

How Florida hospitals are getting ready for Hurricane Dorian

Hurricane Dorian: Central Florida hospitals making sure they’re ready, and free-standing ERs, too

Southwest Florida hospitals are ready for Hurricane Dorian

Palms West Hospital

Memorial Hospital Jacksonville

West Florida Hospital

“Houston’s world-renowned health care infrastructure found itself battered by Hurricane Harvey, struggling to treat storm victims while becoming a victim itself.”

After Hurricane Harvey – Robust Public Health Response

Hurricane Harvey. “There’s no need to test it (flood water),”…“It’s contaminated. There’s millions of contaminants.”…

“Calling 911 (about Hurricane Harvey) didn’t work. Begging for help on Facebook and Instagram failed, too. “I was like, ‘Siri’s smart enough! Let me ask her!’ …

After Hurricane Harvey a man in Texas says he got infected with flesh-eating bacteria

As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save.

It appears that Hurricane Irma evacuation shelter managers may make people wait outside for hours? If so, just welcome them in and then do the registration process inside.

‘This Is Like in War’ – Lessons Learned about Hospital Hurricane Preparedness

The new Jersey City Medical Center (2004) was constructed above the 100 year flood plain – then came Sandy, Harvey & Irma

You are Chief Preparedness Officer at Chiang Rai Region General Hospital in Thailand waiting for the twelve boys and their coach trapped in a cave

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“When you come to a fork in the road, take it.”

Over the years I have collected some aphorisms, quotations and “classics” perhaps worth sharing.

“I made a lot of mistakes in my time but didn’t waste any time making them.” (attributed to Gustave Levy, Goldman Sachs)

“There are no secrets to success. It is the result of preparation, hard work and learning from failure.” (Colin Powell)

“A person who never made a mistake never tried anything new.” (Albert Einstein)

The three umpires (attributed to many):

At a post-season symposium three umpires were discussing “what’s a ball and what’s a strike?”

The rookie umpire said “There are balls and there are strikes and I call them as they are.”

The mid-career umpire said “There are balls and there are strikes and I call them as I seem them.”

The veteran umpire said “There are balls and there are strikes but they ain’t nothing til I call them.”

“Trust, but verify!” (Ronald Reagan)

“If Columbus had an advisory committee he would probably still be at the dock.” (Arthur Goldberg)

“Meetings without an agenda are like a restaurant without a menu.” (Susan B. Wilson)

Dr. Jerome Groopman in “How Doctors Think” developed a classification system for medical mistakes, observing a tendency to treat a case based on past experience rather than looking at it based solely on the evidence.

Vertical Line Failure – thinking inside the box

Confirmation Bias – confirming what you expect to find by selectively accepting or ignoring information

Anchoring –the failure to consider multiple possibilities but quickly and firmly latching on a single one

Availability –an unusual event that recently occurred which has similarities to the current case causing MD to ignore important differences

Commission Bias – tendency toward action rather than inaction due to “bravado”, desperation, or patient pressure

Relying on “Strict Logic” – answering a clinical question in the absence of empirical data

Over-reliance on Clinical Algorithms – simply filling in the blanks on the template

Haste – complicated problems cannot be solved quickly

Outcome Bias – thinking that the diagnosis that is wished for has occurred• Limited Searching –stop searching for a diagnosis once “

This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes. The point is we all fall into comfortable patterns of thinking – our own default classification systems.

“If you’re stuck in a routine that’s limiting your creativity or you’re faced with a challenging business problem and need a fresh approach, you can think outside the box. Or even better, think like there is no box.”

When you’re not sure flip a coin because while the coin is in the air, you realize which one you’re hoping for.” (source unknown)

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. These are things we don’t know we don’t know.” (Donald Rumsfeld)

“No battle plan survives contact with the enemy.” (Helmuth von Moltke the Elder. He was the Chief of Staff of the Prussian army before World War 1)

“Insanity: doing the same thing over and over again and expecting different results.” (Einstein)

“Life is What Happens to You While You’re Busy Making Other Plans.” (John Lennon)

“Never, never, never give up.” (Winston Churchill)

“Don’t depend on anyone else to bring the coffee.” (me)

“The best things in life aren’t things?” (Art Buchwald)

…and the most important

“Character is how you act when no one is watching” (attributed to many)


“When you come to a fork in the road, take it.”  Yogi Berra


“…what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated (health care) delivery system?”

“If you don’t have a seat at the table, you’re probably on the menu.”

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

DON’T DEPEND ON ANYONE ELSE TO BRING THE COFFEE! & other Lessons Learned as a junior hospital CEO back in the day….

“Trust but Verify” (Ronald Reagan) – Four Lessons Learned as a junior CEO back in the day..

Confidential September 11, 2001 LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey gubernatorial campaign issue

If Columbus had an advisory committee he would probably still be at the dock. (A)

We don’t know what we don’t know” (1) The challenge to emergency preparedness…..

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PART 4. San Francisco General, a public hospital with San Francisco’s only trauma center, all commercial insurance WAS “out-of-network.”

See new PART 4 after PARTS 1, 2and 3.

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city “

PART 2: February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

PART 3: April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

PART 4: August 20, 2019. Hospitals kept ER fees secret

ASSIGNMENT: How do other states address financial sustainability for their “safety-net” hospitals?

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off …

“If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city. …But you may leave with a very unpleasant side-effect: a shockingly high bill. …That’s because S.F. General – whose patients are overwhelmingly poor and are on Medicare or Medi-Cal, or have no insurance at all – lacks a good way to deal with patients who are actually insured.” (A)

“Under a new state law, if you visit an in-network facility – such as a hospital, lab or imaging center – you will only be responsible for your in-network share of the cost, even if you’re seen by an out-of-network provider…

The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care, or DMHC, and the state Department of Insurance, which includes roughly 70 percent of the state’s private insurance market, according to the California Health Care Foundation.

It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor…

The key point to remember is that you shouldn’t pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services.” (B)

“The trauma center has no contracts with private insurance companies. If it did, there would be agreements with those insurers on how much a particular drug or a particular procedure costs.

Instead, the hospital charges the highest rates approved by the Board of Supervisors and the mayor, receives whatever amount the patient’s insurance company decides to pay, and bills the patient for the rest.” (C)

On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders – on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that – an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December…

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered “in-network.” Zuckerberg San Francisco General has not done that bargaining with private plans, making them “out-of-network.” That leaves many insured patients footing big bills.

The problem is especially acute for patients like Dang: those who are brought to the hospital by ambulance, still recovering from a trauma and with little ability to research or choose an in-network facility.

A spokesperson for the hospital confirmed that ZSFG does not accept any private health insurance, describing this as a normal billing practice. He said the hospital’s focus is on serving those with public health coverage – even if that means offsetting those costs with high bills for the privately insured.

“It’s a pretty common thing,” said Brent Andrew, the hospital spokesperson. “We’re the trauma center for the whole city. Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”

But most medical billing experts say it is rare for major emergency rooms to be out-of-network with all private health plans. (D)

“The largest public hospital in the city, Zuckerberg San Francisco General cares for 20 percent of all San Franciscans, according to the hospital’s website..

But contrary to the hospital’s position, only 1 percent of ambulance rides nationwide drop patients at out-of-network emergency rooms, according to a study by economist Christopher Garmon at the University of Missouri Kansas City. The study also found that approximately 20 percent of emergency department admissions nationwide resulted in a surprise medical bill. Because of its size and top-tier emergency room, Zuckerberg San Francisco General takes in one-third of ambulances in the city, meaning many of its patients, some unconscious on arrival, are unaware of the hospital’s unusual lack of support for their insurance…

“As a Level 1 trauma center, we must meet certain requirements, 24/7/365, as delineated in the California Code of Regulations (CCR) and by state and national credentialing agencies. The requirements are substantial and, because they require such commitment of resources, costly,” a statement from ZSFG released to Newsweek reads. “We realize there are challenges, difficulties and inefficiencies in our national system of healthcare insurance. We realize burdens are often placed on individuals who are least able to afford them. And we are not in the position of defending the inequities of this system, only working within our prevailing system to the best of our abilities.” (E)

On its web site, ZSFG declares that “everyone is welcome here” regardless of their financial situation or immigration status:

Everyone is welcome here, no matter your ability to pay, lack of insurance, or immigration status. We’re much more than a medical facility; we’re a health care community promoting good health for all San Franciscans.

We’re part of a large group of neighborhood clinics and healthcare providers, the San Francisco Health Network. In partnership, we provide primary care for all ages, specialty care, dentistry, emergency and trauma care, and acute care for the people of San Francisco…

“Our mission is to serve people who are underserved because of their financial needs,” the spokesperson also stated. “We have to be attuned to that population.” (F)

“More than half of U.S. adults “have been surprised by a medical bill that they thought would have been covered by insurance,” according to a new survey from research group NORC at the University of Chicago…

The big picture: Drug prices have been in the crosshairs of lawmakers, and health insurers have always been a punching bag. But hospitals and doctors aren’t attracting any large-scale movement to rein in pricing and billing tactics.

“There’s a huge amount of trust in the providers people choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve got a long way to go until we have backlash against those providers. But as insurance gets more complicated and out-of-pocket costs rise, we’re going to see more and more surprise bills.”

The other side: Ashley Thompson, SVP of policy at the American Hospital Association, said in a statement that “patients and their families should be protected from…unexpected medical bills,” but “insurers have the primary responsibility for making sure their networks include adequate providers.”” (G)

“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on both sides of the aisle are moving closer to an agreement on legislation to prevent surprise medical bills, according to a Bloomberg Government report…

Republicans and Democrats have been working to address the issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told Bloomberg Government…

There have been legislative efforts related to surprise medical bills. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018. The first draft bill focuses on preventing out-of-network providers from charging patients more for emergency care than what they would pay using insurance. The second bars healthcare providers from out-of-network billing for emergency services, according to the report.

Meanwhile, Bloomberg Government notes, insurers and hospitals are pointing the finger at each other over who is at fault for the problem.

Mr. Cassidy told the publication there are “bad apples with both groups” and anticipates both sides “are going to have to give a little bit” when it comes to changes.” (H)

“Congress is considering bipartisan legislation to limit balance billing. But some legal scholars say that patients should already be protected against some of the highest, surprise charges under long-standing conventions of contract law.

That’s because contract law rests on the centuries-old concept of “mutual assent,” in which both sides agree to a price before services are rendered, said Barak Richman, a law professor at Duke University.

Thus, many states require, and consumers expect, written estimates for a range of services before the work is done – whether by mechanics and plumbers or lawyers and financial planners.

But patients rarely know upfront how much their medical care will cost, and hospitals generally provide little or no information.

While consumers are obligated to pay something, the question is how much? Hospitals generally bill out-of-network care at list prices, their highest charges.

Without an explicit price upfront, contract law would require medical providers to charge only “average or market prices,” Richman said.

In several recent cases, for example in New York and Colorado, courts have stepped in to mediate cases where a patient received a big balance bill from an out-of-network provider. They ordered hospitals to accept amounts far closer to what they agree to from in-network private insurers or Medicare.

“This is the amount they are legally entitled to collect,” said Richman…

That complexity – and the cost of hiring an attorney – have made legal challenges to medical bills on the basis of contract law relatively scarce.

Also, “it’s not a well-settled area of the law,” said Hall. “(I)

“Payer groups, including America’s Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.

The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.

Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers…

AHIP said surprise billing happens because providers aren’t participating in certain networks. “When doctors, hospitals or care specialists choose not to participate in networks – or if they do not meet the standards for inclusion in a network – they charge whatever rates they like,” the group wrote.

In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. “Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal,” they wrote…

National leaders have been working on the issue too, but so far a bipartisan effort has only resulted in drafted legislation. The bill would require payers to reimburse out-of-network providers at 125% of the average in-network rate while limiting patient liability to in-network costs.” (J)

“For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read lots of those medical bills – 1,182 of them, to be exact.

My initial goal was to get a sense of how unpredictable and costly ER billing is across the country. There are millions of emergency room visits every year, making it one of the more frequent ways we interact with our health care system – and a good window into the health costs squeezing consumers today…

I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend….

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high – even for things you can buy in a drugstore

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

3) You can be charged just for sitting in a waiting room

4) It is really hard for patients to advocate for themselves in an emergency room setting

5) Congress wants to do something about the issue.. (K)

“Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.

The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”

The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…

But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.

“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”..

The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.” (L)

“Zuckerberg San Francisco General Hospital is reducing a bike crash patient’s $20,243 bill down to $200 – only after the case drew national attention to the hospital’s surprising policy of being out-of-network with all private health insurance…

The San Francisco Board of Supervisors, which oversees the hospital, now plans to hold hearings on Zuckerberg General’s billing practices as well.

“While we as a city should absolutely seek reimbursement from private insurers, we should not be placing the burden of exorbitant bills on patients – who deserve the highest quality care, not the highest possible costs,” said Gordon Mar, the supervisor who chairs the board’s government audit and oversight committee…

Zuckerberg San Francisco General Hospital has not commented on whether it plans to change its policies, and go in-network with private health insurance, although a spokesperson told Vox they are looking into how to make sure other patients don’t end in a situation like Dang’s.

“We are focused on reducing the number of people who could be in this predicament, through a variety of methods, including our own practices, insurance payments, and policy solutions,” spokesperson Rachael Kagan told Vox in an email.” (M)

“Momentum is building for action to prevent patients from receiving massive unexpected medical bills, aided by President Trump, who is vowing to take on the issue.

Calls for action against so-called surprise medical bills have been growing, spurred by viral stories like one involving a teacher in Texas last year who received a $108,951 bill from the hospital after his heart attack. Even though the teacher had insurance, the hospital was not in his insurance network.

Lawmakers in both parties say they want to take action to protect people from those situations, marking a health care area outside of the partisan standoff over ObamaCare, where Congress could advance bipartisan legislation to help patients.

Trump gave a boost to efforts on Wednesday.

“[People] go in, they have a procedure and then all of a sudden they can’t afford it, they had no idea it was so bad,” Trump said at a roundtable with patients about the issue.

“We’re going to stop all of it, and it’s very important to me,” he added.

But the effort still faces obstacles from powerful health care industry groups – including hospitals, insurers and doctors. Those groups are jockeying to ensure that they avoid a financial hit from whatever solution lawmakers and the White House back.” (N)

“And the Republican chairman of the Senate health committee told reporters recently he expects pushback from the industry – but warned industry to act before Congress does. “The first place to deal with it is for the hospitals and doctors and insurance companies to get together and end the practice,” Sen. Lamar Alexander, R-Tenn., said. “And if they don’t, Congress will do it for them.” The senator hasn’t, however, put forward any specific legislation or scheduled hearings on the topic yet.” (O)

“There are 141 million visits to the emergency room each year, and nearly all of them.. have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.

Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.

Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients…

We found that the price of these fees rose 89 percent between 2009 and 2015 – rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.” (P)

“Matt Gleason had skipped getting a flu shot for more than a decade.

But after suffering a nasty bout of the virus last winter, he decided to get vaccinated at his Charlotte, N.C., workplace in October. “It was super easy and free,” said Gleason, 39, a sales operations analyst.

That is, until Gleason fainted five minutes after getting the shot. Though he came to quickly and had a history of fainting, his colleague called 911. And when the paramedics sat him up, he began vomiting. That symptom worried him enough to agree to go to the hospital in an ambulance.

He spent the next eight hours at a nearby hospital – mostly in the emergency room waiting area. He had one consult with a doctor via teleconference as he was getting an electrocardiogram. He was feeling much better by the time he saw an in-person doctor, who ordered blood and urine tests and a chest-X-ray.

All the tests to rule out a heart attack or other serious condition were negative, and he was sent home at 10:30 p.m.

And then the bill came.

Total Bill: $4,692 for all the hospital care, including $2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83 for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer, Blue Cross and Blue Shield of North Carolina, negotiated discounts for the in-network hospital and reduced those costs to $3,711. Gleason is responsible for that entire amount because he had a $4,000 annual deductible. (The ambulance company and the ER doctor billed Gleason separately for their services, each about $1,300, but his out-of-pocket charge for each was $250 under his insurance.)..

The biggest part of Gleason’s bill – $2,961 – was the general ER fee. Atrium coded Gleason’s ER visit as a Level 5 – the second-highest and second-most expensive – on a 6-point scale. It is one step below the code for someone who has a gunshot wound or major injuries from a car accident. Gleason was told by the hospital that his admission was a Level 5 because he received at least three medical tests.

Gleason argued he should have paid a lower-level ER fee, considering his relatively mild symptoms and how he spent most of the eight hours in the ER waiting area.

The American Hospital Association, the American College of Emergency Physicians and other health groups devised criteria in 2000 to bring some uniformity to emergency room billing. The different levels reflect the varying amount of resources (equipment and supplies) the hospital uses for the particular ER level. Level 1 represents the lowest level of ER facility fees, while ER Level 6, or critical care, is the highest. Many hospitals have adopted the voluntary guidelines…

Blue Cross and Blue Shield of North Carolina said in a statement that the hospital “appears to have billed Gleason appropriately.” It noted the hospital reduced its costs by about $980 because of the insurer’s negotiated rates. But the insurer said it has no way to reduce the general ER admission fee…

Gleason, in fighting his bill, actually got the hospital to send him its entire “chargemaster” price list for every code – a 250-page, double-sided document on paper. He was charged several hundred dollars more than the listed price for his Level 5 ER visit…

Resolution: After Gleason appealed, Atrium Health reviewed the bill but didn’t make any changes. “I understand you may be frustrated with the cost of your visit; however, based on these findings, we are not able to make any adjustments to your account,” Josh Crawford, nurse manager for the hospital’s emergency department, wrote to Gleason on Nov. 15.” (Q)

Zuckerberg hospital puts balance billing on hold

Mayor London Breed and Supervisor Aaron Peskin Announce Halt to Balance Billing at Zuckerberg San Francisco General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented

Friday, February 01, 2019

“Department of Public Health and ZSFG will develop a comprehensive plan for improvements within 90 days to address the issue of patients being billed the balance of their bills when their private insurers refuse to cover their bills

San Francisco, CA -Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) announced immediate steps to improve billing practices at ZSFG for patients who have gotten stuck in the middle of disputes between the hospital and their insurance provider, including a temporary halt to the practice of balance billing.

The San Francisco Department of Public Health (DPH) operates ZSFG as part of the San Francisco Health Network, the City’s public health care system. As San Francisco’s public hospital, the vast majority of ZSFG patients have Medi-Cal, Medicare or are uninsured. About 6 percent of patients have commercial insurance (including HMO or PPO plans) and come to ZSFG through trauma and emergency services. For those patients, their insurance is billed for services, and the insurance company decides what to pay. When an insurance company does not pay in full, PPO patients can be billed for the balance, a practice known as “balance billing.”

“Although ‘balance billing’ affects a very small number of ZSFG patients, the stress and hardship they experience when it happens is very real,” said Mayor Breed. “We need to look hard at our current billing practices, and until we come up with a plan that works for patients, we will not continue the practice of balance billing. In an emergency, people’s focus should be on getting help quickly, not on what hospital they should go to. Private insurance companies also need to be held accountable to actually pay for the healthcare for anyone they cover.”

“The City is taking the right step by stopping the practice of balance billing at SF General, because there’s nothing ‘balanced’ about it,” said Supervisor Peskin. “It’s extra billing for services that patients don’t have a choice about receiving, further delaying their ability to move on and heal. This immediate halt also covers the previous patients who’ve been stuck with crippling bills, including those being sent to collections. Healing delayed is healing denied, so I’m looking forward to working with the Department of Public Health on a new path forward.”

Greg Wagner, Acting Director of Health, and Dr. Susan Ehrlich, CEO of ZSFG, outlined a set of immediate actions and elements of a comprehensive plan for improvement that will be developed within 90 days. This includes making changes to billing practices, financial assistance and patient communications. In addition, DPH and ZSFG are exploring policy solutions in coordination with local and state elected officials.

“The billing practices at Zuckerberg San Francisco General Hospital and Trauma Center for privately insured patients who receive trauma and emergency services are not working for some of our patients,” Wagner said. “Keeping the patients’ experience as the focal point, we will explore ways to protect patients from financial hardship, increase participation in financial assistance programs and where possible, recover costs for services from insurers to avoid lost revenues to the City.”

“While hospital billing in the United States is very complicated, patients should not be caught in the middle of disputes between hospitals and insurance companies,” Ehrlich said. “At ZSFG, our mission is to provide high quality health care and trauma services with compassion and respect to everyone in San Francisco. We are working to ensure that our billing practices better align with that mission. We are sensitive to people’s circumstances and our patients come from all over the economic spectrum. We cannot solve the problems of the entire health care system, but we can do better to serve San Franciscans, who consistently have supported ZSFG and the rest of the City’s excellent public health programs and services.”

DPH and ZSFG have continued to address the problem of insurance payment shortfalls. DPH sued insurers for underpayment and reached settlements, reducing the number of privately insured patients who might be affected by a dispute. DPH’s patient financial services department works with individuals year-round to help them with billing issues, including financial assistance and appeals to insurance plans.

Immediate Changes

Temporarily halt all balance billing of patients

Effective immediately until a better plan is determined

Make financial assistance easier to get

Proactively begin the process of assessing a patient’s eligibility for assistance, rather than waiting for them to apply

Improve patient communications

Proactively reach out to patients who are receiving large bills to explain the situation, remove the element of surprise, and offer to help

Create a Frequently Asked Questions document to clear up many of the routine questions about billing and financial assistance

Publicize the patient financial services hotline, (415) 206-8448, so that people know where to go for help

Increase communication with patients and provide information about financial assistance opportunities

Additional elements of a comprehensive plan to be developed within 90 days

Make financial assistance easier to get

Adjust charity care and sliding scale policies to expand the number of people who are eligible

Revise ZSFG catastrophic high medical expense program to support more patients who are faced with high, unexpected bills for catastrophic events

Streamline the process of applying for assistance

Protect patients’ financial health

Establish an out-of-pocket maximum for patient payments to ZSFG

Pursue agreements with private insurance companies

Work with state partners to explore additional efforts to improve insurance payments

Ensure ZSFG prices and practices are fair

Undertake a study of hospital charges regionally, comparing trauma centers, academic medical centers, San Francisco and Bay Area hospitals

Research billing and financial assistance practices of California public hospitals to identify opportunities for improvement

Conduct financial analysis of impact on the City of proposed changes (R)

(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured,

(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar,

(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight,

(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah,

(E)Zuckerberg Hospital ER Doesn’t Take Private Insurance, Sticking San Francisco Patients With Huge Bills, by Andrew Whalen,

(F)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels,

(G)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit,

(H)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels,

(I)Why there’s no surprise hospital bill backlash – yet,

(J) Payer, hospital groups trade blame on surprise billing, by Les Masterson,

(K)Taking Surprise Medical Bills To Court, by Julie Appleby,

(L))Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff,

(M) After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff,

(N)Trump boosts fight against surprise medical bills, by PETER SULLIVAN,

(O)Industry braces as more lawmakers seek to ban surprise billing, by Shannon Mushmore,

(P) Sarah Kliff has spent the past year reporting on high ER fees. Ask her anything, by Lauren Katz,

(Q)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kliff,

(R)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented,

PART 2:  February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash – a move they say was inspired by Vox’s reporting on the issue.

The new bill, introduced by Assemblyman David Chiu and Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance.

“These practices are outrageous,” says Chiu, who represents part of San Francisco in the state assembly. “No one who is going through the trauma of emergency room care should be subsequently victimized by outrageous hospital bills.”..

California actually has some of the country’s strongest protections against surprise medical bills – but the state’s laws never anticipated a hospital with billing practices like Zuckerberg San Francisco General.

In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.

This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.

That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.

Neither the court ruling nor the 2016 law anticipated a situation like Zuckerberg San Francisco General, where the entire hospital is “out of network” with all private health insurance.”..

“This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.

There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.

Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.

“Patients would no longer receive exorbitant, surprise bills,” says Chiu. “The discussion between insurers and hospitals would become far more predictable.” ” (A)

“”At the heart of what we are trying to do is to ensure that if you or are a loved one are in the ER, the only thing you should be thinking about is how to get better and not about the bill for that care,” said Chiu.

He said that the bill is a response “in regard to what we learned is happening at [ZSFGH] – but also across California – this is the situation of patients who get a surprise bill after visiting an emergency room.”..

Rachael Kagan, a spokesperson for the San Francisco Public Health Department, which manages the hospital, said in a statement on Friday that the department can’t comment on the proposed legislation but that “we absolutely agree that there is a role for policy changes to improve patients’ experience with billing,” including “local state and federal efforts.”

She added that the hospital and department are working in the meantime on making improvements. One proposal so far suggests capping out-of-pocket payments made by insured patients receiving emergency services, as was previously reported by the San Francisco Examiner.” (B)

Joint Surprise Billing Letter to Congress and Committee Leadership (C)

Dear Congressional and Committee Leadership:

On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from “surprise bills” that result from unexpected gaps in coverage or medical emergencies. We appreciate your leadership on this issue and look forward to continuing to work with you on a federal legislative solution.

Surprise bills can cause patients stress and financial burden at a time of particular vulnerability: when they are in need of medical care. Patients are at risk of incurring such bills during emergencies, as well as when they schedule care at an in-network facility without knowing the network status of all of the providers who may be involved in their care. We must work together to protect patients from surprise bills.

As you debate a legislative solution, we believe it is critical to:

Define “surprise bills.” Surprise bills may occur when a patient receives care from an out-of-network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when: (1) a patient accesses emergency services outside of their insurance network, including from providers while they are away from home; (2) a patient receives care from an out-of-network physician providing services in an in-network hospital; or (3) a health plan denies coverage for emergency services saying they were unnecessary.

Protect the patient financially. Patients should have certainty regarding their cost-sharing obligations, which should be based on an in-network amount. Providers should not balance bill, meaning they should not send a patient a bill beyond their cost-sharing obligations.

Ensure patient access to emergency care. Patients should be assured of access to and coverage of emergency care. This requires that health plans adhere to the “prudent layperson standard” and not deny payment for emergency care that, in retrospect, the health plan determined was not an emergency.

Preserve the role of private negotiation. Health plans and providers should retain the ability to negotiate appropriate payment rates. The government should not establish a fixed payment amount or reimbursement methodology for out-of-network services, which could create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks.

Remove the patient from health plan/provider negotiations. Patients should not be placed in the middle of negotiations between insurers and providers. Health plans must work directly with providers on reimbursement, and the patient should not be responsible for transmitting any payment between the plan and the provider.

Educate patients about their health care coverage. We urge you to include an educational component to help patients understand the scope of their health care coverage and how to access their benefits. All stakeholders – health plans, employers, providers and others – should undertake efforts to improve patients’ health care literacy and support them in navigating the health care system and their coverage.

Ensure patients have access to comprehensive provider networks and accurate network information. Patients should have access to a comprehensive network of providers, including in-network physicians and specialists at in-network facilities. Health plans should provide easily-understandable information about their provider network, including accurate listings for hospital-based physicians, so that patients can make informed health care decisions. Federal and state regulators should ensure both the adequacy of health plan provider networks and the accuracy of provider directories.

Support state laws that work. Any public policy should take into account the interaction between federal and state laws. Many states have undertaken efforts to protect patients from surprise billing. Any federal solution should provide a default to state laws that meet the federal minimum for consumer protections.

We look forward to opportunities to discuss these solutions and work together to achieve them.


American Hospital Association

America’s Essential Hospitals

Association of American Medical Colleges

Catholic Health Association of the United States

Children’s Hospital Association

Federation of American Hospitals

PART 3. April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.

The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.

After the Vox story ran, the hospital reduced Dang’s bill to $200, the copay listed on her insurance card.

Now, Zuckerberg San Francisco General Hospital (ZSFG) is essentially making the same change for all future patients: Its new billing policies will no longer charge those with private coverage “any more than they would have paid out of pocket for the same care at in-network facilities, based on their insurance coverage.”

This will put an end to the hospital’s use of a controversial practice call “balance billing,” when a hospital sends a patient a bill for the balance that an insurer won’t pay.

ZSFG will also create a new out-of-pocket maximum on what patients could end up owing for their treatment. The maximum is tethered to a patient’s income and ranges from zero dollars for the lowest earners to a $4,800 maximum for those with the highest incomes (1,000 percent of the poverty line, or $251,400 for a family of four).” (A)

“The changes are aimed at shielding patients from large bills by removing them from payment disputes between the hospital and the insurance company, said Rachael Kagan, director of communications with the department.

“We don’t have a large number of privately insured patients at Zuckerberg San Francisco General Hospital, but some of those who have been in that situation in the past have had a terrible experience and we want to rectify that,” said Ms. Kagan.

“We don’t want that to happen in the future. We know that it’s very stressful to get a large bill and we consider our responsibility to the patients to care for them in all ways. They will have gotten excellent medical care from us, and we want to protect their financial well-being also,” she added.

The hospital estimated that up to 1,700 of its 104,000 patients a year may have received a balance bill…

Zuckerberg hospital will also set a maximum out-of-pocket cost for patients at all income levels, with any insurance status, and this maximum will be income-based. No one will be charged more than 5 percent of their income…

Additionally, the hospital will make its patient financial assistance programs easier to qualify for so more people will get financial assistance. This involves increasing the threshold to qualify for the hospital’s charity care program. The threshold to qualify will increase from 350 percent of the federal poverty level to 500 percent of the federal poverty level.

The hospital is also adjusting the “sliding scale” financial assistance program for San Francisco residents. Previously, Zuckerberg hospital assessed eligibility for the program based on income and assets but will now only take income into account…

Overall, she said she’s pleased the hospital is taking these steps to better align its billing with its values and mission.” (B)

“We may get called the “enemy of the people,” but the press can make a real difference in forcing the powers that be into changing some of their most horrific and unfair practices. Consider Zuckerberg San Francisco General Hospital, which has been hounded by pesky reporters covering their “aggressive billing tactics” with privately insured patients.

In the wake a January Vox report showing a fully insured woman was charged $20,000 for a broken arm and a San Francisco Chronicle exposé detailing a $92,000 appendectomy, the city’s only trauma center (named for a billionaire worth $70 billion, give or take) has announced a significant change to its billing policy. The Chronicle reports that Zuckerberg General is reversing the policy, and establishing “out-of-pocket” maximum that should not exceed $4,800 for patients with copays. Vox got a copy of the announcement which claims the practice was “was halted on February 1, 2019 and will not resume.”

The practice is called “balance billing,” an Orwellian term that indicates some sort of fairness and balance in a system that bills fully insured patients tens of thousands of dollars for routine injury treatments. Zuckerberg General, which primarily serves Medicare, Medi-Cal, and uninsured patients, had employed an unusual system where fully insured patients’ insurance companies could just choose how much they wanted to cover or not cover, effectively ignoring whatever copay amount they had communicated to the patient.” (C)

“A doctor assured DeAnn Allen the trace of blood in her urine after a car crash was just a little bruising, but she wouldn’t have guessed it by the size of her bill.

That urine test and visit with the doctor cost Allen, who was visiting Las Vegas, more than $1,800.

“If you care about your care, and have a choice, we urge you to go somewhere else!” Allen wrote in a review on Facebook for Elite Medical Center, Las Vegas’ newest emergency hospital situated just west of the Strip.

Just like any full-service emergency room, Elite Medical Center treats a range of urgent medical problems, from headaches to heart attacks. But unlike the other ERs in Southern Nevada, you’ll generally pay more for your care.

That’s because the facility doesn’t contract with any insurer. So if you break a bone or your child has an earache and you go there, you’ll be paying for out-of-network care.

Elite is licensed as a hospital by the state, but experts say it is operating similarly to freestanding emergency rooms that have become common recently in other states. It is the only unaccredited hospital in Clark County that provides emergency care but doesn’t contract with insurers…

There’s no license for a freestanding ER in Nevada, though hospitals are allowed to open satellite emergency rooms that provide care at other locations.

Elite Medical Center pursued a different path by getting the state to license it as a hospital. That means the facility has the capacity to keep patients for 48 hours.

State law doesn’t mandate these facilities be accredited by the federal Centers for Medicare or Medicaid Services or accept any insurance, private or public.” (D)

  1. A.After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff,
  2. B.Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch,
  3. C.Zuckerberg Hospital Revises Insane Billing Practices After Media Exposés, by JOE KUKURA,
  4. D.Emergency room off Las Vegas Strip makes waves with new business model, by Milbank News Writer,

PART 4: August 18, 20129. Hospitals kept ER fees secret.

Zuckerberg San Francisco General and the University of California San Francisco are two of the city’s busiest hospitals, about 4 miles apart. But if you have private insurance and visit Zuckerberg General, you could end up paying a lot more for the same treatment.

For an especially serious visit, Zuckerberg General charges a facility fee of $11,176, 46 percent more than UCSF, which charges an average of $7,635.

The hospital is also out-of-network with all private insurance, leaving patients responsible for the fee and the cost of treatment. UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers generally negotiate lower prices for patients, and many plans cover ER visits in part or in full…

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings.

These charges, known as “facility fees,” are the price that patients pay for walking in the door of an emergency room and seeking service. Nationally, these fees are kept secret. Patients only learn their emergency room’s facility fee when they receive a bill after the visit…

We found that privately insured patients seen at Zuckerberg General end up with significantly bigger bills than those seen at other nearby emergency rooms. For example, the hospital charged a $5,369 facility fee for a patient who presents with a “severe” emergency…

The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.

The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”

The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…

The fees at Zuckerberg General have nearly doubled over the past decade. In 2010, the emergency room fees at the hospital ranged from $287 to $6,118, depending on the severity of the visit. Now the prices range from $525 to $11,958.

But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.

“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.” (A)

“California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash — a move they say was inspired by Vox’s reporting on the issue.

The new bill, introduced by state Assembly member David Chiu and state Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance.

“These practices are outrageous,” says Chiu, who represents part of San Francisco in the Assembly. “No one who is going through the trauma of emergency room care should be subsequently victimized by outrageous hospital bills.”..

Zuckerberg San Francisco General Hospital has, in light of reporting from both Vox and the San Francisco Chronicle, promised to revise its billing policies to be more patient-friendly. The hospital is reportedly considering a cap on charges for privately insured patients.

But Chiu thinks that even more action is needed: a statewide law that would outlaw this kind of behavior…

This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.

There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.

Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.

“Patients would no longer receive exorbitant, surprise bills,” Chiu said. “The discussion between insurers and hospitals would become far more predictable.”

Chiu said the hospital and insurance industries are aware of the effort but haven’t yet seen the full text of the legislation, which will be introduced on Monday.”  (B)

“Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups — health insurers and health providers — have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered “comprehensive,” according to the Commonwealth Fund. California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada, which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California’s protections don’t cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn’t apply to the millions of residents with health plans regulated by the federal government…

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region…

 “We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern,” she said.

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.” (C)

“Legislation to prohibit California hospitals from sticking patients with huge emergency room bills that their insurers won’t cover has cleared a crucial hurdle in the state Capitol.

Lawmakers in the Assembly voted 48-9 on Thursday to approve AB1611, which would prohibit hospitals from “balance billing” patients if their insurance won’t cover the full cost for care.

Assemblyman David Chiu and state Sen. Scott Wiener, both Democrats from San Francisco, co-wrote the legislation. The bill now moves to the Senate.

They wrote the bill in response to Chronicle stories about patients who had undergone treatment at San Francisco General Hospital, often for minor injuries, and been billed tens of thousands of dollars even though they had insurance.

 “After a trip to the emergency room, the only thing you should be focused on is getting better,” Chiu said. “Not a bill for tens of thousands of dollars.”

San Francisco General had billed patients for the difference between the cost of their treatment and what their insurance companies were willing to pay. The hospital announced in April that it would end the practice, meaning patients won’t be billed beyond what their insurance requires.

AB1611 would prohibit hospitals from billing patients for any cost beyond their insurance deductible and co-payment. It also spells out rules for how hospitals and insurers resolve cost disputes.” (D)

 “Zuckerberg is notorious for being not necessarily the worst but one of the worst places to go in terms of prices for emergency care,” Anderson continued. “The prices are outrageously high. They are notorious for it. And everybody knows about them.”

The maddening element about hospital billing is that the costs charged to patients are only abstractly related to the costs incurred by the hospital.

“They do not need to justify their charges. They have full discretion,” explains Ge Bai, a Johns Hopkins professor of both accounting and health management and policy. “There are no regulatory forces to limit their ability to set a high charge. The charge is coming purely from the hospital and subject to no external forces.” 

Patients — especially uninsured patients — “become prey of this charging game.”…

The No. 1 reason that hospitals aggressively bill their most vulnerable patients? That, too, is relatively easy to grasp. It’s the same reason people from around the world phone you up and demand your Social Security Number: A very small percentage of folks give them everything they want.

Hospitals “don’t get most of the money — in most cases,” says Anderson. “It’s simply preferable for them to charge $3,300 and get it from some people rather than charge $200 and get it from nearly everybody.”  (E)

“Hospitals focused their opposition on a provision of the bill that would have limited charges for out-of-network emergency services.

The proposal would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. (Photo: Shutterstock)

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.” (F)

The attempt by two San Francisco politicians to stop hospitals around California from sticking patients who receive emergency care with outrageous bills is on life support.

“Assemblyman David Chiu on Tuesday said he is holding back his bill that was inspired by news of San Francisco General Hospital’s unfair billing practices after intense lobbying from hospital CEOs around the state urging his colleagues to kill it.

The bill was supposed to be heard in the Senate’s health committee Tuesday, but Chiu said its passage would have required amendments making the bill worthless, and he wasn’t willing to move ahead with them.

Instead, he’s turning the bill into a two-year piece of legislation, meaning it can be taken up again in January. But that means the earliest Gov. Gavin Newsom can sign it is September, 2020. And that means the 7 million Californians who have private insurance and yet are still at risk of big emergency care bills won’t see any relief for more than a year — if at all.

“It’s disappointing this couldn’t get done this year,” Chiu said. “But this doesn’t mean we’re done. It ain’t over.”” (G)

“Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.”

Chiu said he and his team would keep working on amendments to the bill that address the concerns of hospitals while maintaining protections for patients.

Hospitals focused their opposition on a provision of the bill that would have limited what they can charge insurers for out-of-network emergency services, criticizing it as an unnecessary form of rate setting.” (H)

“San Francisco’s health network has finalized its first contract with a private health insurer, Canopy Health Canopy — meaning Zuckerberg San Francisco General Hospital, long perceived as the hospital of last resort, is now in the business of wooing expectant mothers to choose to deliver at its Family Birth Center…

Department of Public Health staff said the signing of this contract was not a reaction to billing controversies at ZSFGH that erupted earlier this year, when it was revealed that even insured patients were being hit with crippling debts through the practice of “balance billing.” Because the hospital was out-of-network for private insurance companies, there was often a great divergence between what ZSFGH billed the insurance and what the insurance company would deign to pay — leaving individuals responsible for the “balance.”

This situation, however, did highlight the hospital’s unhealthy and precarious “payer mix.” With few privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals like the one initiated July 15 with Canopy would begin to change that mix, however.

“It is good for the hospital to diversify its revenue with different payors,” notes Department of Public Health spokeswoman Rachael Kagan. “We have been working to accomplish private contracting for some time now.”

Inundating the hospital with better-paying privately insured patients at the expense of publicly insured patients would be cause for concern. But this doesn’t figure to happen at the Family Birthing Center, one of the few departments at ZSFGH that isn’t overloaded beyond capacity.

Kagan says the Department of Public Health hopes 60 privately insured Canopy patients deliver at ZSFGH. Hospital staff have been told to expect up to 80. This would represent a small bump in the total number of deliveries at the hospital, which is about 1,200 a year.

Just how many privately insured mothers opt to deliver at ZSFGH will depend on how effectively the hospital sells itself as the “good and safe place to have a baby” — and how effectively it can dispel the perception that anyone who could afford to go elsewhere would do so.

Hospitals competing for patients — especially expectant mothers — often play up amenities more closely resembling a luxury resort than a medical center: private rooms, steak dinners, sumptuous views.

It remains to be seen if ZSFGH will go this route. What it does have to offer, however, is a 24-hour/seven-day on-call midwife — which no other city hospital does. ZSFGH also claims the lowest C-section rate in all San Francisco.

Kagan declined to reveal whether the city is in negotiation with other private insurers, which could alter ZSFGH’s payer mix even more. The Canopy deal required three years to close. So it would be surprising if others aren’t in the works, if not imminent.

“Our hope is that down the road we can expand access to more of our services to Canopy Health and other commercially insured patients,” wrote Roland Pickens, the director of the city’s Health Network, in the inter-office memo announcing this deal. “ (I)

“California hospitals want you to know that they’re fully on board with the idea that emergency room patients shouldn’t be hit with thousands of dollars in surprise billings because the ER isn’t in their insurance plan’s network.

You should also know, however, that the hospitals just killed a measure in Sacramento that would have accomplished that goal, and that the reason they did so was to protect their own revenues….

Chiu’s legislation had two major pieces. It prohibited hospitals from charging out-of-network ER patients more than they would charge an in-network patient for the same services. It also established a standard for what a hospital could charge a non-network insurer. In other words, the bill limited what patients would pay hospitals out of pocket but set rules on what insurers would pay the hospitals too.

Originally, the bill set 150% of Medicare reimbursement as a payment benchmark. The sponsors eventually amended that to whatever rate is “reasonable and customary,” defined as the average in-network contracted rate in a hospital’s geographic region. Hospitals could appeal for higher reimbursements through the state Department of Health Care Services.

The state’s hospitals went to the mattresses over the payment provision, cursing it as “government rate setting” that they would never accept. Hospital executives inundated legislators with warnings that rate-setting would force their institutions to shut down…

The proponents were aware that they were poking a stick into a tiger’s cage. “We’re going after a practice that has generated billions of dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the state waged very aggressive lobbying to protect those profits.”” (J)

“Twelve Connecticut hospitals charge patients a trauma activation fee when they arrive by ambulance with a serious injury.

These fees, ranging in the thousands of dollars, are unregulated. And 11 of the 12 Connecticut trauma centers won’t reveal publicly how much they charge…

(Only designated trauma centers are permitted to charge trauma activation fees, which can add thousands of dollars to hospital bills.)

A trauma fee is charged when a trauma team is called to attend to a patient with significant or life-threatening injuries who is brought to the hospital by emergency medical services. Only designated trauma centers can use the billing code 068x to charge a trauma activation fee.

These fees are set by the hospitals and can range based on the level of response a patient requires. They help hospitals recoup the costs of having highly trained doctors and specialized nurses on call to respond to tragedies at a moment’s notice. Insurance sometimes covers the fees so not all patients may notice them buried in their hospital bill — if they have health insurance…

Connecticut has four hospitals designated as level I trauma centers, 7 that are level II and one level III. These levels refer to the resources available in the trauma center and the amount of patients admitted yearly — but its unclear if they have any correlation with the amount charged for trauma fees.” (K)

  1. A.Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff,
  2. B.After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff,
  3. C.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra,
  4. D.Legislation prompted by huge SF General bills passes California Assembly, by Dustin Gardiner,
  5. E.The cost of *one stitch* at Zuckerberg San Francisco General Hospital? $3,300, by Joe Eskenazi,
  6. F.
  7. G.Legislation to stop patients getting massive ER bills is on life support, by Heather Knight,
  8. H.Hospitals Block ‘Surprise Billing’ Measure, by Ana B. Ibarra,
  9. I.San Francisco inks first contract with private health insurer, by Joe Eskenazi,
  10. J.Column: How the hospital lobby derailed legislation to protect you from surprise hospital bills, by MICHAEL HILTZIK,
  11. K.CT hospital’s ‘trauma fees’ under state scrutiny, by Emilie Munson,
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