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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)
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
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
“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
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
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
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.”
“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
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
“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
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
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
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
“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
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
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).
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
“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
“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
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
Montag says they plan to include the name of the impacted
facilities in their annual infection report, which will be released later this
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
“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
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),
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
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
“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
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
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
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
“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
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
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
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
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
“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
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
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
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)
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
Doctors sometimes struggle to diagnose fungal infections, in
part because their symptoms are little different from those of bacterial
‘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
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
“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
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
“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
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
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
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.”
“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)
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 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, myUpchar.com…
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
“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?…
“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
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
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
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
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
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
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
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
– 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
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.
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
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
By DAVID M. HALBFINGER
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
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
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
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
”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.”
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
– 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.”
“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
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
Should providers and suppliers have to tell patients how
high their out-of-pocket costs are expected to be before providing a
“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
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
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
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
“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,”
“Out-of-network.” How could that happen? Remember,
she got written confirmation from Banner Gateway Hospital indicating she was
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
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
“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
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
“The health insurer Anthem is coming under intense
criticism for denying claims for emergency room visits it has deemed
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)
PART 2. Private Equity is a Driving Force Behind Devious
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
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
“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
“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
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
“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
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
..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
“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
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
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
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
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
This is particularly important with the recent merger
activity in South Jersey with some hospitals tied to health systems in
“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
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
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
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
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)
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
“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
Before scheduling it, he called the hospital, the surgeon
and the anesthesiologist to get estimates for how much the procedure would
“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
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
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
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
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
Providers who do not have contracts with insurers are
considered out-of-network and can bill patients directly for the full cost of
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
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
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,
“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
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
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
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
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
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
“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
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
“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
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
“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
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
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
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
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
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
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:
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
Starting with the sources below prepare your 15 minute
We don’t know what we don’t know” The challenge to emergency
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
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)
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
How do other states address financial sustainability for their “safety-net”
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
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
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
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
“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
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
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
“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
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
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
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
Without an explicit price upfront, contract law would
require medical providers to charge only “average or market prices,”
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
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
“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
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
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
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
“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
The San Francisco Board of Supervisors now plans to bring
greater scrutiny to the hospital’s billing practices in light of Vox’s
“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
“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
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.”
“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
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
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
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.
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
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
Streamline the process of applying for assistance
Protect patients’ financial health
Establish an out-of-pocket maximum for patient payments to
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
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
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
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
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
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
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
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
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
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.
, 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
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
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
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
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)
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
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
“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
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
The state law governing non-emergency care also doesn’t
apply to the millions of residents with health plans regulated by the federal
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
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)
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
“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
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
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
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
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
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
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
“Twelve Connecticut hospitals charge
patients a trauma activation fee when they arrive by ambulance with a serious
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
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)