By Andrew Jacobs, New York Times, Aug. 21, 2021.

Cyndy O’Brien, an emergency room nurse at Ocean Springs Hospital on the Gulf Coast of Mississippi, could not believe her eyes as she arrived for work. There were people sprawled out in their cars gasping for air as three ambulances with gravely ill patients idled in the parking lot. Just inside the front doors, a crush of anxious people jostled to get the attention of an overwhelmed triage nurse.

“It’s like a war zone,” said Ms. O’Brien, who is the patient care coordinator at Singing River, a small health system near the Alabama border that includes Ocean Springs. “We are just barraged with patients and have nowhere to put them.”

The bottleneck, however, has little to do with a lack of space. Nearly 30 percent of Singing River’s 500 beds are empty. With 169 unfilled nursing positions, administrators must keep the beds empty.

Nursing shortages have long vexed hospitals. But in the year and half since its ferocious debut in the United States, the coronavirus pandemic has stretched the nation’s nurses as never before, testing their skills and stamina as desperately ill patients with a poorly understood malady flooded emergency rooms. They remained steadfast amid a calamitous shortage of personal protective equipment; spurred by a sense of duty, they flocked from across the country to the newest hot zones, sometimes working as volunteers. More than 1,200 of them have died from the virus.

Now, as the highly contagious Delta variant pummels the United States, bedside nurses, the workhorse of a well-oiled hospital, are depleted and traumatized, their ranks thinned by early retirements or career shifts that traded the emergency room for less stressful nursing jobs at schools, summer camps and private doctor’s offices.

“We’re exhausted, both physically and emotionally,” Ms. O’Brien said, choking back tears.

Like hospital leaders across much of the South, Lee Bond, the chief executive of Singing River, has been struggling to stanch the loss of nurses over the past year. Burnout and poaching by financially flush health systems have hobbled hospitals during the worst public health crisis in living memory.

With just over a third of Mississippi residents fully vaccinated, Mr. Bond is terrified things will worsen in the coming weeks as schools reopen and Gov. Tate Reeves doubles down on his refusal to reinstate mask mandates. “Our nurses are at their wits’ end,” Mr. Bond said. “They are tired, overburdened, and they feel like forgotten soldiers.”

Across the country, the shortages are complicating efforts to treat hospitalized coronavirus patients, leading to longer emergency room waiting times and rushed or inadequate care as health workers struggle to treat to patients who often require exacting, round-the-clock attention, according to interviews with hospital executives, state health officials and medical workers who have spent the past 17 months in the trenches.

The staffing shortages have a hospital-wide domino effect. When hospitals lack nurses to treat those who need less intensive care, emergency rooms and I.C.U.s are unable to move out patients, creating a traffic jam that limits their ability to admit new ones. One in five I.C.U.s are at least 95 percent capacity, according to an analysis by The New York Times, a level experts say makes it difficult to maintain standards of care for the very sick.

“When hospitals are understaffed, people die,” said Patrica Pittman, director of the Health Workforce Research Center at George Washington University.

Oregon’s governor has ordered 1,500 National Guard troops to help tapped-out hospital staff. Officials in a Florida county where hospitals are over capacity are urging residents “to consider other options” before calling 911. And a Houston man with six gunshot wounds had to wait a week before Harris Health, one of the country’s largest hospital systems, could fit him in for surgery to repair a shattered shoulder.

“If it’s a broken ankle that needs a pin, it’s going to have to wait. Our nurses are working so hard, but they can only do so much,” said Maureen Padilla, who oversees nursing at Harris Health. The system has 400 openings for bedside nurses, including 17 that became vacant in the last three weeks.

In Mississippi, where coronavirus cases have doubled over the past two weeks, health officials are warning that the state’s hospital system is on the verge of collapse. The state has 2,000 fewer registered nurses than it did at the beginning of the year, according to the Mississippi Hospital Association. With neighboring states also in crisis and unable to take patient transfers, the University of Mississippi Medical Center in Jackson, the only Level 1 trauma unit in the state, has been setting up beds inside a parking garage.

“You want to be there in someone’s moment of need, but when you are in disaster mode and trying to keep your finger on the leak in the dike, you can’t give every patient the care they deserve,” said Dr. LouAnn Woodward, the medical center’s top executive. With staffing shortfalls plaguing hospitals coast to coast, bidding wars have pushed salaries for travel nurses to stratospheric levels, depleting staff at hospitals that can’t afford to compete. Many are in states flooded with coronavirus patients.

Texas Emergency Hospital, a small health system near Houston that employs 150 nurses and has 50 unfilled shifts each week, has been losing experienced nurses to recruiters who offer $20,000 signing bonuses and $140-an-hour wages. Texas Emergency, by contrast, pays its nurses $43 an hour with a $2 stipend for those on the night shift. “That’s ridiculous money, which gives you a sense of how desperate everyone is,” said Patti Foster, the chief operations officer of the system, which runs two emergency rooms in Cleveland, Texas, that are over capacity.

Ms. Foster sighed when asked whether the hospital offered signing bonuses. The best she can do is pass out goody bags filled with gum, bottled water and a letter of appreciation that includes online resources for those overwhelmed by the stress of the past few weeks.

Business has never been better for travel nurse recruiters. Aya Healthcare, one of the country’s biggest nurse recruitment agencies, has been booking 3,500 registered nurses a week, double its prepandemic levels, but it still has more than 40,000 unfilled jobs listed on its website, said April Hansen, the company’s president of work force solutions. “We’re barely making a dent in what’s needed out there,” she said.

There were more than three million nurses in the United States in 2019, according to the Bureau of Labor Statistics, which estimates 176,000 annual openings for registered nurses across the country in the next few years. But those projections were issued before the pandemic.

Peter Buerhaus, an expert on the economics of the nursing work force at Montana State University, is especially rattled by two data points: A third of the nation’s nurses were born during the baby boom years, with 640,000 nearing retirement; and the demographic bulge of aging boomers needing intensive medical care will only increase the demand for hospital nurses. “I’m raising the yellow flag because a sudden withdrawal of so many experienced nurses would be disastrous for hospitals,” he said.

Many experts fear the exodus will accelerate as the pandemic drags on and burnout intensifies. Multiple surveys suggest that nurses are feeling increasingly embattled: the unrelenting workloads, the moral injury caused by their inability to provide quality care, and dismay as emergency rooms fill with unvaccinated patients, some of whom brim with hostility stoked by misinformation. Nurses, too, are angry — that so many Americans have refused to get vaccinated. “They feel betrayed and disrespected,” Professor Buerhaus said.

Increasing the nation’s nursing workforce is no easy task. The United States is producing about 170,000 nurses a year, but 80,000 qualified applicants were rejected in 2019 because of a lack of teaching staff, according to the American Association of Colleges of Nursing.

“We can’t graduate nurses fast enough, but even when they do graduate, they are often not prepared to provide the level of care that’s most needed right now,” said Dr. Katie Boston-Leary, director of nursing programs at the American Nurses Association. Newly minted nurses, she added, require on-the-job education from more seasoned ones, placing additional strains on hospital resources.

Some of the proposed remedies include federal policies that can stabilize the profession, including financial assistance to help nursing schools hire more instructors and staffing-ratio mandates that limit the number of patients under a nurse’s care.

“This simplistic notion that the labor market will just produce the number of nurses we need just isn’t true for health care,” said Professor Pittman of George Washington University. “Nursing is in crisis, and maybe the pandemic is the straw that will break the camel’s back.”

The crisis is on full display at Texas Emergency Hospital, which has been treating patients in hallways and tapping administrators to run specimens to the lab. In recent days, 90 percent of those admitted to the hospital have tested positive for the coronavirus. Short on ventilators, and with hospitals in Houston no longer able to take their most critically ill patients, officials have been contemplating the unthinkable: how to ration care.

On Friday, Cassie Kavanaugh, the chief nursing officer for the hospital’s network, was dealing with additional challenges: Ten nurses were out sick with Covid. She had no luck renting ventilators or other breathing machines for her Covid patients. Many of the new arrivals are in their 30s and 40s and far sicker than those she saw during previous surges. “This is a whole different ballgame,” she said.

Ms. Kavanaugh, too, was running on fumes, having worked 60 hours as a staff nurse over the previous week on top of her administrative duties. She was also emotionally wrought after seeing co-workers and relatives admitted to her hospital. And her anguish only mounted after she stopped at the grocery store: Almost no one, she said, was wearing masks.

“I don’t know how much more we can take,” she said. “But one thing that hit me hard today is a realization: If things keep going the way they are, we’re going to lose people for sure, and as a nurse, that’s almost too much to bear.”

A federal judge has dismissed a lawsuit brought by 117 employees at Houston Methodist Hospital who were suing the hospital system over its COVID-19 vaccine requirement.

In a five-page ruling issued Saturday, U.S. District Judge Lynn Hughes upheld the hospital’s vaccination policy, saying the requirement broke no federal law.

“This is not coercion,” said Hughes. “Methodist is trying to do their business of saving lives without giving them the COVID-19 virus. It is a choice made to keep staff, patients, and their families safer.”

The decision marked the latest development in a standoff that began in April when Houston Methodist announced that all staff would be required to be vaccinated against COVID-19 by June 7. The hospital says that nearly all of its roughly 26,000 employees agreed to the policy, but suspended nearly 200 staff members without pay for refusing to comply.

The 178 employees suspended by the hospital argue that the vaccines are unsafe and even “experimental.” The hospital has responded by saying that hundreds of millions of vaccine doses have been safely administered after a vetting process that included three rounds of clinical trials.

The judge compared the challenge to a press release

In his ruling, Judge Hughes called the plaintiffs’ claim that currently available COVID-19 vaccines are “experimental and dangerous” an argument that is both false and irrelevant. “Texas law only protects employees from being terminated for refusing to commit an act carrying criminal penalties to the worker,” Hughes wrote, adding that the “press-release style of the complaint” fails to specify what illegal acts the plaintiffs were alleged to have been asked to perform.

“Receiving a COVID-19 vaccination is not an illegal act, and it carries no criminal penalties,” the judge wrote.

The judge also denounced the plaintiffs for equating the vaccine mandate to forced experimentation by the Nazis against Jewish people during the Holocaust. “Equating the injection requirement to medical experimentation in concentration camps is reprehensible,” Hughes said. “Nazi doctors conducted medical experiments on victims that caused pain, mutilation, permanent disability, and in many cases, death.”

Houston Methodist has been among the first hospitals in the nation to require staff to be inoculated against the coronavirus, and the judge’s decision marked an early test of how challenges to similar bans may hold up in the courts.

The plaintiffs say their fight isn’t over

Jared Woodfill, the lawyer representing the plaintiffs, told NPR they’re not done “fighting this unjust policy.” In a written statement, he said his clients are committed to appealing the decision.

“What is shocking is that many of my clients were on the front line treating COVID-positive patients at Texas Methodist Hospital during the height of the pandemic,” he said. “As a result, many of them contracted COVID-19. As a thank you for their service and sacrifice, Methodist Hospital awards them a pink slip and sentences them to bankruptcy.”

Houston Methodist welcomed the decision, writing in a statement on Saturday that it was “pleased and reassured after U.S. District Judge Lynn Hughes today dismissed a frivolous lawsuit filed by some employees who fought our COVID-19 vaccine mandate.”

Covid is mostly made up or exaggerated by the media.

According to Johns Hopkins, experts in public health, there have been more than 35 million cases of Covid-19 in the U.S. and more than 600,000 people have died from it.

Only OLDER people or those with a PRE-EXISTING CONDITION get Covid or die from it.  

Anyone who has not been vaccinated can get the virus, transit it to others, and die. Seniors and people with serious underlying medical conditions may be more susceptible but a 2 month old baby has also died from it.

The Covid vaccine can give you Covid. 

Covid vaccines don’t contain any live virus so they can’t give you Covid.

The vaccine was developed too quickly, hasn’t been properly tested, and isn’t safe.           

Scientists were able to produce a vaccine quickly because it was a worldwide effort. Coronaviruses have been studied for fifty years and pre-existing technology developed over ten years was used to develop a number of different Covid vaccines. Those that were not effective or not safe were abandoned. All Covid vaccines now available have had unprecedented safety monitoring. The Covid vaccine was assessed for safety in tens of thousands of patients. More than 3.8 billion doses have been administered worldwide and over 340 million here in the U.S., according to Oxford University.

The vaccine can cause infertility or make you sterile.

It’s not possible for any Covid vaccine to alter your DNA, which would be needed to cause infertility or make you sterile.

The vaccine can kill a pregnant woman or her unborn child.

There’s no evidence that any Covid vaccine causes problems with pregnancy. Thousands of pregnant women have gotten the vaccine and are fine. If an unvaccinated woman gets pregnant and then gets Covid there is a greater risk of death or severe illness.

The vaccine isn’t effective.

No vaccine, even the flu vaccine, is 100% effective but Covid vaccines have proven to be some of the most effective ever developed.

The vaccine causes serious side effects.

The main side effects of any of the Covid vaccines are temporary aches and pains as the immune system revs up to fight off the virus. Not everyone will have these side effects. Some will only have a sore arm for a day or so and maybe a slight fever. None of the side effects compare to possibly losing your life or infecting someone else who does.

I’ve already had Covid so I don’t need the vaccine and I shouldn’t get it.

If you’ve had Covid your natural immunity will probably not last as long as the immunity you get from the vaccine. Since there’s no way of knowing if you have any natural protection it’s important to get vaccinated. It won’t harm you if you have had Covid.

The vaccine is just a way for Bill Gates to put a microchip in me.

The Covid vaccine does not contain any microchips.

Find a vaccine near you.

Copyright © 2021, the American Patient Rights Association. May be copied, reproduced, and transmitted in whole only. All other rights reserved.

Summary:  COVID long haulers are struggling hard to receive the medical care for their symptoms and being dismissed.

Last summer, in the six weeks after she began feeling terrifyingly breathless and was briefly hospitalized for Covid-19, Crystal Williams returned to the emergency room eight times. Each visit was for dizziness and shortness of breath, for which she often received fluids and oxygen. She didn’t get any answers as to why her symptoms had persisted, though, and despite having insurance, she ran up tens of thousands of dollars worth of medical bills.

“At first, doctors listened, but they became dismissive the longer things went on,” said Williams, 30, a Tacoma, Wash., cosmetologist. “For months, I could barely walk down the hall to the bathroom without getting winded.”

By September, her breathing problems had begun to wane, but Williams was plagued by a host of other symptoms, including chest pain, severe headaches, dizziness, exhaustion, and brain fog. She had difficulty focusing on a task and remembering things that were once easily filed away, and her heart raced with even minor movements. She eventually learned that this constellation of problems had a name: long Covid.

After many months, Williams discovered through a Facebook group for people with long Covid that specialists such as a cardiologist and a sleep doctor might be able to help her. Although it took two months to book these appointments, and another month to undergo tests that were recommended, Williams was finally able to start to get her concerns addressed — seven months after her symptoms had begun.

Williams is just one of thousands of people with long Covid who have struggled to receive medical care for their symptoms. Many have found that even if they’re able to see a doctor, it can be difficult to be heard, and the best treatments remain unclear.

Medical centers across the country are opening clinics specifically for people with lingering Covid symptoms, aiming to harness the expertise of specialists ranging from pulmonologists to physical therapists to neurologists. But many long Covid sufferers are located far from such a clinic, and the waitlist to be seen often is long. For example, the Cleveland Clinic’s post-Covid recovery center, reCOVer clinic, welcomed 113 patients in its first month, and as of mid-March, the clinic’s next available appointments were at the end of July. Penn Medicine’s Post-Covid Assessment and Recovery Clinic in Philadelphia has enrolled 458, with a three-month waitlist for new patients.

According to recent research, fatigue, shortness of breath, and headaches are among the most common symptoms of long Covid, along with digestive issues and ongoing fevers. It’s not known how many people have the condition, which is also known as post-acute sequelae of SARS-CoV-2 infection or long-haul Covid, but the United Kingdom’s Office for National Statistics estimates 1 in 10 people with a symptomatic Covid infection feel sick for at least 12 weeks. A study published in February found that nearly one-third of people reported persistent symptoms at least three months after an initial Covid infection – most commonly fatigue and lack of taste or smell.

Notably, two-thirds of patients seen in Cleveland Clinic’s long Covid center had not required hospitalization for their infection, indicating that those with milder infections can develop the syndrome.

Lizzie Elliott, a 19-year-old student at Ursinus College in Pennsylvania, said when she developed exhaustion, a racing heart rate, and trouble breathing after a Covid infection in February 2020, connecting with doctors who truly listened was a major challenge. The impact of these symptoms was clear: What used to be a five-minute walk to the dining hall took 10 minutes, and her previously easy mile-long stroll to work had become impossible.

A cardiologist Elliott saw for her racing heartbeat, however, dismissed the symptom as anxiety. Doctors attributed her breathing problems to her asthma, despite the fact they felt quite different from her asthma flares. And a physical therapist did not seem to grasp how even the gentlest physical activity left Elliott exhausted and gasping.

“No one was listening to me,” said Elliott, who eventually found a primary care physician receptive to her concerns and was ultimately able to enroll in Penn Medicine’s post-Covid clinic.

Although the clinic has been helpful, the onus remains on the Elliotts “to seek out skilled diagnosticians willing to seek out the latest research and educate themselves on how to develop treatment plans for patients like Lizzie,” said Jennifer Elliott, Lizzie’s mother.

“It really still comes down to doctors being willing to listen to patients and caregivers, as they are experts in living with their condition,” she said. When that falls into place, however, it can be a breakthrough.

The Elliotts were able to find, for example, “a stunningly skilled physical therapist who listens to Lizzie describe how she is feeling based on activities he prescribes, and responds or pivots accordingly,” said Jennifer Elliott.

The duration of long Covid symptoms is variable, and it’s not known which treatments might be best, although researchers are on the case: In December, Congress granted the National Institutes of Health $1.15 billion to study the longer-term health consequences of Covid-19.

Kristin Englund, an infectious diseases physician who runs Cleveland Clinic’s long Covid clinic, said she hopes clinics like hers can connect patients with experts who are up to date on symptoms and treatments that may help.

“There’s a tremendous amount of need out there, unfortunately,” said Englund, “and we are trying to ramp up quickly to be of help to people.”                      

The financial fallout

In late 2020, just as Williams was beginning to feel a bit better, her financial situation took a turn for the worse. As a cosmetologist whose business had been shuttered during the pandemic — first temporarily, then permanently — she’d been getting by on unemployment benefits and federal stimulus checks.

“Initially, I thought I was going to go back to work,” said Williams, who is a single mother to her 9-year-old son. “Then I realized I couldn’t even walk to my bathroom. There was no way I could do hair.” She began to fall further and further behind on her bills.

Losing her job also left her without insurance just when she needed it most. Since then, she’s purchased coverage through the state of Washington but still faces hefty copayments. She’s prioritizing buying the medicines that have helped so far because she knows if she stops taking them, she may feel worse. The psychological and financial stress of accruing debt has taken a toll.

“I have to pick which bills I can pay,” she said, and the costs keep accruing. “I am scared to find out how much I owe from all of this.”

And that doesn’t leave much cash for anything else — for herself or her son. “Thank goodness rental assistance came through this winter, or we wouldn’t have had a Christmas,” she said.

Bruce Wheeler, a retired retail banker, also has struggled with debilitating fatigue and headaches since catching Covid in mid-March 2020.

“I can get up at 8 a.m., and at 9:30 a.m. be ready for a nap, and then need another nap in the afternoon,” said Wheeler. “I also used to get piercing headaches every day, as if there was a knife cutting into my temples; it would just stop me in my tracks.” The headaches have improved, he said, but the fatigue has lingered.

Williams, too, continues to struggle with exhaustion. She dedicates an entire day to attending a doctor’s appointment, for example, because taking a shower and getting dressed is so exhausting she needs to nap for a few hours afterwards before heading out the door.

The path ahead

As clinicians and scientists learn more about long Covid, there’s hope that therapies will emerge to help. Until then, people with long Covid emphasized the importance of leaning on a support system and of not being afraid to speak up.

“Do your best to advocate for yourself, don’t let doctors put words in your mouth, and take as much help as you can get,” said Williams, who lives in the same apartment building as her mother and sister. Without them, she said, she would be lost.

Garrett, too, has been sustained by the dedication of her family as well as drop-off deliveries of soup and baked goods from friends and others in her extended community.

“I have a very supportive husband who is basically doing everything,” she said. “I can’t imagine what I would have done if I didn’t have someone to rely on.”

Wheeler found it helpful to connect with a support group of others grappling with long Covid. “To find six other people going through the same thing I was, showing I wasn’t alone, and that this wasn’t psychosomatic — this has been a really big part of my recovery and emotional well-being so far.”

Williams also tries to share her story wherever she can in the hopes of fostering greater understanding of what it’s like to have long Covid. If people can glimpse a day in the life of someone with the condition, she hopes, it might persuade them to take measures to prevent catching the virus in the first place.

“I try to share what I am going through,” she said, “because people just don’t understand what it’s like.”

Article link: https://www.statnews.com/2021/04/21/long-covid-patients-struggle-to-get-care-for-their-symptoms/

When Darius Settles died from COVID-19 on the Fourth of July, his family and the city of Nashville, Tenn., were shocked. Even the mayor noted the passing of a 30-year-old without any underlying conditions — one of the city’s youngest fatalities at that point.

Settles was also uninsured and had just been sent home from an emergency room for the second time, and he was worried about medical bills. An investigation into his death found that, like many uninsured COVID-19 patients, he had never been told that cost shouldn’t be a concern.

Back at the end of June, Settles and his wife, Angela, were both feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.

“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the 911 recordings obtained by WPLN News.

Darius Settles was stabilized and tested for the coronavirus at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.

Three days later, they did. And now he also knew he had COVID-19; his test results were in.

But Settles was also between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance.

His wife, who works for Tennessee State University, says he was worried about costs as he went back to the hospital a second time; she tried to reassure him

“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she says.

When he returned to TriStar Southern Hills Medical Center, owned by the for-profit hospital chain HCA, physicians tested his blood oxygen levels, which are usually a first sign that a COVID-19 patient is in trouble. They had dropped to 88%. An X-ray of his lungs “appears worse,” the physician wrote in the record.

But the doctor also noted that his oxygen saturations improved, and he was breathing on room air after a few hours in the emergency room. The records show they discussed why he might not want to be admitted to the hospital since he was otherwise young and healthy and didn’t note any risk factors for complications.

And when Angela Settles called to check in, he seemed to be OK with leaving despite his persistent struggle to breathe.

He was a COVID-19 patient so, “I could not go up there to see him,” she says. “He was saying that I might as well go home.”

Angela Settles was surprised since her husband was the one who wanted to go to the hospital in the first place.

At first, she thought the hospital just didn’t want to admit a man without insurance who would have trouble paying a big bill. But TriStar Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson.

And in this case, the federal government would have paid the bill. But no one said that when it might have made a difference to Darius Settles.

Message never makes it to patients
TriStar, like most major health systems, participates in a program through the Centers for Medicare and Medicaid Services in which uninsured patients with COVID-19 have their bills covered. It was set up through the pandemic relief legislation known as the CARES Act.

But TriStar doesn’t tell its patients that upfront. Neither do other hospitals or national health systems contacted by WPLN News. There’s no requirement to, which is one of the program’s shortcomings, says Jennifer Tolbert of the Kaiser Family Foundation who studies uninsured patients. (KHN is an editorially independent program of the foundation.)

“This is obviously a great concern to most uninsured patients,” Tolbert says. Her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they asked enough questions.

Tolbert says the problem with the COVID-19 uninsured program is that even doctors don’t always know how it works or that the program exists.

“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she says. “And it’s not always clear that that is happening.”
Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay, under a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.

Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.

“I don’t want to absolutely promise anything,” says Ryan Stanton, an ER physician in Lexington, Ky., and a board member of the American College of Emergency Physicians.

“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the health care system,” he says.

“Could I have done more?”
Darius Settles knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles, and asked his father to come pray for him.

When the elder Settles replied that he was always praying for his son, Darius said, “No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,” David Settles recalls, and so he went, despite concern for getting COVID-19 himself.

He sat by his son’s side. Darius’ wife made some peppermint tea, and when they put it to his lips, Darius didn’t sip. They thought he had fallen asleep. But he was unconscious.

At that point, they called 911 again and the operator instructed them to get Darius to the floor and perform chest compressions until paramedics arrived.
For 11 minutes, Angela Settles pumped her husband’s chest, occasionally asking the dispatcher “what’s taking so long,” the 911 recordings show. Even after help showed up, Darius never revived.

Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “The Lord gives, and the Lord takes away.”

Darius Settles left behind his own son, who was 6. And his widow’s head is still spinning. She says she can’t shake a sense of personal guilt.

“Could I have done more?” Angela Settles asks. “That’s hard, and I know that he would not want me to feel like that.”

She wonders, too, if the hospital could have done more for him. And even after failing to disclose its policy for uninsured COVID-19 patients, it did send her a bill for part of her husband’s care. Asked why, a TriStar spokesperson says it was sent in error and does not have to be paid.

Article link: https://www.npr.org/sections/health-shots/2020/10/22/925942412/hospital-bills-for-uninsured-covid-19-patients-are-covered-but-no-one-tells-them

As she waited for the results of her rapid COVID-19 test, Rachel de Cordova sat in her car and read through a stack of documents given to her by SignatureCare Emergency Center.

Without de Cordova leaving her car, the staff at the freestanding emergency room near her home in Houston had checked her blood pressure, pulse and temperature during the July 21 appointment. She had been suffering sinus stuffiness and a headache, so she handed them her insurance card to pay for the $175 rapid-response drive-thru test. Then they stuck a swab deep into her nasal cavity to obtain a specimen.

De Cordova is an attorney who specializes in civil litigation defense and maritime law. She cringes when she’s asked to sign away her rights and scrutinizes the fine print. The documents she had been given included disclosures required by recent laws in Texas that try to rein in the billing practices of stand-alone emergency centers like SignatureCare. One said that while the facility would submit its bill to insurance plans, it doesn’t have contractual relationships with them, meaning the care would be considered out-of-network. Patients are responsible for any charges not covered by their plan, it said, as well as any copayment, deductible, or coinsurance.

The more she read, the more annoyed de Cordova became. SignatureCare charges a “facility fee” for treatment, the document said, ranging “between five hundred dollars and one hundred thousand dollars.” Another charge, the “observation fee,” could range from $1,000 to $100,000.

De Cordova didn’t think her fees for the test could rise into the six figures. But SignatureCare was giving itself leeway to charge almost any amount to her insurance plan — and she could be on the hook. She knew she couldn’t sign the document. But that created a problem: She still needed to get her test results.

Even in a public health emergency, what could be considered the first rule of American health care is still in effect: There is no set price. Medical providers often inflate their charges and then give discounts to insurance plans that sign contracts with them. Out-of-network insurers and their members are often left to pay the full tab or whatever discount they can negotiate after the fact.

The CARES Act, passed by Congress in March, includes a provision that says insurers must pay for an out-of-network COVID-19 test at the price the testing facility lists on its website. But it sets no maximum for the cost of the tests. Insurance representatives told ProPublica that the charge for a COVID-19 test in Texas can range from less than $100 to thousands of dollars. Health plans are generally waiving out-of-pocket costs for all related COVID-19 treatment, insurance representatives said. Some costs may be passed on to the patient, depending on their coverage and the circumstances.

As she waited, de Cordova realized she didn’t want to play insurance roulette. She changed her mind and decided she’d pay the $175 out-of-pocket for her test. But when the SignatureCare nurse came to collect the paperwork, de Cordova said the nurse told her, “You can’t do that. It’s insurance fraud for you to pay for our services once we know you have insurance.”

Dr. Hashibul Hannan, an emergency room physician, lab director, and manager at SignatureCare, told ProPublica his facility is an emergency room that offers testing, not a typical testing site. He said de Cordova should have been allowed to pay the $175 cash price. The staff members were concerned about being accused of fraud because they had already entered her insurance information into the record, he said. So they didn’t want it to appear she was being double-billed. Hannan also said he regrets that she was upset by the disclosure forms that are now required under state law.

Unable to pay cash and unwilling to take a chance on the unknown cost, de Cordova decided to leave without getting the results of her COVID-19 test.

“I Would Have Signed Anything”

Later that day, de Cordova couldn’t get past what happened. She wondered what happened to patients who didn’t read the fine print before signing the packet.

Then she realized she and her husband, Hayan Charara, could investigate it themselves. In June, the couple’s 8-year-old son had attended a baseball tryout. They thought the kids would be socially distanced and that precautions would be taken. But then the coaches had crowded the players in a dugout, with no masks or social distancing, and a couple of days later the boy said he wasn’t feeling well.

So just to be safe, on June 12, Charara took their son to the same SignatureCare, the Heights location, for a COVID-19 test. The line was so long they had to wait for hours, go home, come back and wait for hours again in their car in the 100-degree heat. Charara, a poet who teaches at the University of Houston, said he didn’t take a close look at the financial disclosure paperwork. De Cordova wasn’t with them. It had been 10 hours of waiting by the time the boy was tested, so “I would have signed anything,” he said. (The child tested negative.)

Charara, de Cordova, and their children are covered by the Employees Retirement System of Texas, a taxpayer-funded benefit plan that covers about half a million people. They hadn’t received any notices about the charges for their son. So, they contacted the SignatureCare billing department and asked for an itemized statement. The test charge was indeed $175. But the total balance, including the physician and facility fees associated with an emergency room visit, came to $2,479.

The facility fee was $1,784 and the physician fee $486.

The couple were dumbfounded. Their son’s vital signs had been checked but there had been no physical examination, they said. The interactions took less than five minutes total, and the child stayed in the car. “You’re getting a drive-thru test, and they’re pretending like they’re giving you emergency services,” de Cordova said.

The SignatureCare charges shocked experts who study health care costs. Charging $2,479 for a drive-thru COVID-19 test is a “nauseating” example of profiteering during a pandemic, said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit organization that studies health care prices. “It’s one of the most egregious examples of giving the fox the keys to the henhouse I’ve ever seen and yet another example of the absurdity of U.S. health care pricing.

“Imagine a vendor in any other walk of life being allowed to bill a third party for whatever amount they wanted,” Brennan said.

Insurance companies in Texas typically pay between $100 and $300 for drive-thru COVID-19 tests, said Jamie Dudensing, CEO of the Texas Association of Health Plans. But the association’s members have seen hundreds of out-of-network COVID-19 test charges come in far higher, some in the thousands of dollars.

“There’s no excuse for that, especially in a public health crisis,” said Chris Callahan, spokesperson for Blue Cross and Blue Shield of Texas, which likewise has seen high charges for COVID-19 tests from out-of-network providers.

The reimbursement rates negotiated between insurance companies and in-network providers are much lower, but they still vary, according to data provided by the nonprofit FAIR Health, which tracks spending by private insurers. For the same test billed by SignatureCare, an in-network insurer pays a median price of $23 in Utah and $75 in Wisconsin, according to FAIR Health estimates.

Texas is notorious for its high-priced out-of-network emergency bills and free-standing emergency departments. Some of the facilities appear to be using COVID-19 testing to draw in patients so their insurance plans can be charged for additional services, said Blake Hutson, associate state director for AARP Texas, the advocacy organization for older Americans. “It’s not a surprise they would be racking up the charges and adding on everything they can and billing the health plan,” he said.
In some cases, insurers do pay the exorbitant out-of-network charges, Hutson said, but they typically get reduced. In 2019, Texas lawmakers voted to ban billing patients in state-regulated insurance plans for charges not covered by their policy, Hutson said, which is known as “balance” or “surprise” billing. But consumers may still be responsible for any deductibles and other cost-sharing under their health plan. And the costs covered by the health plan get passed back to the consumers over time in the form of higher premiums, he said. “It’s all problematic for the cost of care,” Hutson said.

Hannan defended SignatureCare’s high out-of-network charges by blaming insurance companies for refusing to give what he considers to be fair in-network rates. The charges are a starting point for negotiating a fair deal from out-of-network insurance plans, he said. He described SignatureCare, which has 18 locations, as “small players. When it comes to negotiating with insurance companies, we have no luck.”

Was the Bill Accurate?

The medical record portrays the visit as an emergency and contains details that are not consistent with how Charara and de Cordova describe their son’s condition. The chief complaint in the record is “body fluid exposure,” and elsewhere it says “confirmed COVID exposure.”

But that’s not accurate, according to the parents. No one had coughed or sneezed on their son, and they knew of no one from the tryout who had tested positive for COVID-19, they said. The child’s temperature is registered in the record as 102.8, which is high. But Charara said that could have been caused by sitting in the Texas heat, waiting for the test.

Shelley Safian, a Florida health care coding expert who has written four books on medical billing, examined the bill and medical records of Charara and de Cordova’s son at ProPublica’s request. She said the medical records don’t justify the charges. SignatureCare billed the case as if the exam were an emergency that required an “expanded problem focused history” and “medical decision making of moderate complexity,” she said.

In order to qualify for reimbursement of an exam at that level, the encounter would need to include examining the affected organ system, Safian said. But the medical records do not document any check of the respiratory system, which would be indicated for suspected COVID-19.

Much of the medical record appeared to be cut and pasted from other electronic records, Safian said. “This is boilerplate B.S.,” she said, “and I don’t mean ‘bachelor of science.’”

Hannan, the SignatureCare doctor and manager, stands by the charges associated with the child’s COVID-19 test. The facility has to treat every case like a possible emergency, and that requires an examination, he said. He pointed out that the charges are in line with what other out-of-network providers would charge in the area, according to FAIR Health, though they are far higher than in-network prices.

A doctor’s examination may not be as hands-on during COVID-19, but, similar to a telemedicine visit, a lot can be examined visually, Hannan said. Hannan said the company he uses for coding said COVID-19 requires a higher level of care and vigilance because it’s an infectious disease.

In light of the questions raised by ProPublica and Safian, Hannan said he asked his billing company to audit the charges. Sharon Nicka, president and CEO of Nicka and Associates, the billing company used by SignatureCare, took issue with Safian’s assessment and said the billing codes used were justified by the medical record. She said the charges are high for a drive-thru test, but those are set by SignatureCare.

ProPublica identified several apparent errors and contradictions in the medical record and billing documentation. For example, the notes in the medical record alternatively refer to the boy as “symptomatic” and “asymptomatic.” The record also says the physical exam showed a skin wound that “was not red, swollen or tender,” but the child had no wound of any kind, the family said. And the billing documentation shows a charge for an antibody test when the medical record showed that the patient actually received a diagnostic test, which is something different.

In response to ProPublica’s questions, a SignatureCare medical director reviewed the record. The error about the “wound” may have been caused by a software template adding something that was not in the physician chart, the reviewer wrote. The facility now uses a different template. The charge for the antibody test is likely a billing error, as the physician had ordered the correct test, the reviewer wrote. “We will continue to update and improve our (electronic medical records),” the reviewer said.

Hannan stressed that SignatureCare is upfront with patients about the possible fees associated with its treatment, including the disclosure paperwork and explanations on its website. It’s an emergency room, he said, so patients should expect emergency room fees. Patients who do not have a medical emergency should not come, he said, though the ER allows patients to book appointments a day in advance for a COVID-19 test.

Dudensing, the chief executive of the Texas Association of Health Plans, said she’s heard Hannan’s contention before and it’s true that freestanding emergency rooms have a license that allows them to charge more. But she still believes that they handle many non-emergency cases and are forcing facility fees of thousands of dollars on them. “They’re hiding under the guise of emergency rooms when they’re really dressed-up urgent care,” she said.

Diana Kongevick, director of group benefits for the Employees Retirement System of Texas, said the health plan had only recently received the bill for the 8-year-old’s test. It hadn’t been processed, so she could not speak to it directly. But, in general, the health plan will pay 100% of the cost of the test, in this case $175, she said. The claim would be processed using out-of-network provisions, she said. So for the other charges, the patient may be responsible for paying in the range of $600, she estimated, for the out-of-network copay and deductibles. “This is a nonemergent patient self-referral to an out-of-network provider,” Kongevick said.

“Testing Should Be Free”

Even if the Employees Retirement System of Texas determines that Charara and de Cordova should pay $600 for their son’s test, SignatureCare will not be sending the family a bill, Hannan said. He said insured patients are not being sent bills for COVID-19 treatment beyond what their insurance companies cover.

De Cordova never did get her test results, and she didn’t seek a test elsewhere. She felt better later and now believes she had just been suffering from allergies. But what if it had turned out to be COVID-19, she wondered. Might she have gone on to infect others, she’s asked herself.

From a public health perspective, the haggling about out-of-network charges and payments puts patients in the middle, and it might discourage them from getting tested for COVID-19 during the pandemic, said Stuart Craig, an economist at the University of Pennsylvania who studies health care costs. “It’s another part of the fragmentation of the health care system that makes patients’ lives miserable,” Craig said.

It’s especially frustrating, he said, because COVID-19 testing is so essential to making it safely through the pandemic. Craig said he believes there should be a nationally mandated price and government subsidies to make sure medical providers and manufacturers are motivated financially to provide tests. “Testing should be free,” Craig said. “In fact, we should probably be paying patients to get tested.”

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