Tagged California

Nursing Home Safety Violations Put Residents At Risk, Report Finds

As huge swaths of California burned last fall, federal health officials descended on 20 California nursing homes to determine whether they were prepared to protect their vulnerable residents from fires, earthquakes and other disasters.

The results of their surprise inspections, which took place from September to December of 2018, were disturbing: Inspectors found hundreds of potentially life-threatening violations of safety and emergency requirements, including blocked emergency exit doors, unsafe use of power strips and extension cords, and inadequate fuel for emergency generators, according to a report released Thursday by the U.S. Department of Health and Human Services Office of Inspector General.

The nursing home residents “were at increased risk of injury or death during a fire or other emergency,” the report concluded.

The threat is not theoretical in a state that has been ravaged by natural disasters: One of the nursing homes that was inspected burned down in a wildfire afterward, so the report only includes results for the 19 remaining facilities, which it does not identify.

“The fact that one of the nursing homes inspected was later destroyed by a wildfire speaks to the grave danger residents are facing today,” said Mike Connors of the advocacy group California Advocates for Nursing Home Reform. He called the findings alarming but not surprising.

Even though the report didn’t name the nursing home that was destroyed, the California Association of Health Facilities, which represents most of the state’s skilled nursing facilities, identified it as one that burned down in the November 2018 Camp Fire, the deadliest wildfire in the state’s history.

Craig Cornett, CEO and president of the association, said all the residents were evacuated safely from that home — and from two others destroyed in the same fire. Hundreds of other nursing homes also have responded to emergencies in the past three years without loss of life, he said, which shows that “the deficiencies in the report do not reflect true facility readiness.”

The association is concerned about safely violations, he added, but “this is an example of bureaucracy equipped with blinders.”

The federal auditors said the violations occurred because of poor oversight by management and high staff turnover at the homes. But they also criticized the California Department of Public Health, the agency responsible for overseeing nursing homes in the state, for not ensuring the homes complied with federal safety and emergency requirements.

In some cases, the state’s own inspectors had previously cited nursing homes for the same problems, but did not inspect the facilities again to ensure they had been fixed, the report said.

The department “can reduce the risk of resident injury or death by improving its oversight,” the report said. For example, it could “conduct more frequent site surveys at nursing homes to follow up on deficiencies previously cited rather than relying on reviews of documentation submitted by nursing homes.”

The public health department told the auditors it had followed up with the 19 remaining homes to ensure they were addressing the problems auditors identified. But the state disagreed with the auditors’ recommendation to inspect nursing homes more frequently, saying in a letter to the auditors that federal rules don’t require onsite visits to determine whether problems have been fixed — and that the agency simply does not have enough inspectors.

The department declined a California Healthline request for comment.

The Office of Inspector General is auditing nursing homes across the nation that receive payments from the public health insurance programs Medicare or Medicaid to determine whether the facilities meet the stricter federal safety and emergency guidelines that were adopted in 2016. The auditors did not choose the 20 nursing homes randomly out of the approximately 1,200 statewide, but rather selected those in fire- and earthquake-prone regions, as well as ones already on notice for health and safety violations.

The inspectors found a total of 325 violations at the 19 homes. Among them:

  • Two of the homes had pathways leading to emergency exit doors that were blocked, including one exit door blocked by a pallet.
  • 16 had violations related to their fire alarm and sprinkler systems, including two that didn’t have their fire alarm systems routinely tested and maintained.
  • All had violations related to electrical equipment, including using power strips that did not meet requirements or were unsafely connected to appliances or other power strips.
  • Eight had not properly inspected, tested and maintained their emergency generators, which provide electricity for critical medical equipment during a power outage. Two didn’t have enough generator fuel to last 96 hours. Generator power has become critical for nursing homes in recent months amid widespread power shutdowns aimed at preventing wildfires.
  • Three nursing homes’ emergency plans didn’t address evacuations.

“We don’t want reports like this,” said state Sen. John Moorlach (R-Costa Mesa). “It sounds like maybe we need to ask the state auditor to see if the site visits done by the state are being done thoroughly.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Aging California Public Health

More Vapers Are Making Their Own Juice, But Not Without Risks

MENLO PARK, CALIF. — Danielle Jones sits at her dining room table, studying the recipe for Nerd Lyfe (v2) vape juice. The supplies she’s ordered online are arrayed before her: a plastic jug of unflavored liquid nicotine, a baking scale and bottles of artificial flavors that, combined, promise to re-create the fruity taste of Nerds Rope candy in vapor form.

This is Jones’ first attempt to make her own e-liquid after buying it for the past five years. Jones, 32, wants to be prepared for the worst-case scenario: a ban on the sale of the e-liquids she depends on to avoid cigarettes.

“Even though I haven’t touched a cigarette in five years, the pull is always there. It’s so easy to go and buy a pack. And I don’t want to do that,” she said. “The only route I can see going forward if there is a ban is to try to create the product myself at home.”

As more states, cities and even the federal government consider banning flavored nicotine, thousands of do-it-yourself vapers like Jones are flocking to social media groups and websites to learn how to make e-liquids at home.

Users on the forums — many of whom have been mixing their own e-liquids for years — describe the process as simple, fun, cheap and, with the proper precautions, safe. But if not done carefully, making e-liquids at home may pose risks including accidental exposure to high doses of liquid nicotine, the use of dangerous oil-based flavors and possible product contamination.

“To have people mixing their own e-cigarette liquid is crazy. These are very toxic chemicals,” said Stanton Glantz, a professor of medicine and the director of the Center for Tobacco Control Research and Education at the University of California-San Francisco. “If you drop a little bit of nicotine on your skin, it can send you to the hospital.”

Jones makes her own vape juice and orders the supplies she needs — small scale, plastic containers, a funnel, nicotine mix and artificial flavors — online.(Heidi de Marco/KHN)

Jones holds an unflavored liquid nicotine mix which she ordered online.(Heidi de Marco/KHN)

But Dr. Michael Siegel, a professor of community health sciences at Boston University, said many people are able to make vaping liquids safely at home, by seeking advice from other vapers and following a few safety measures, such as wearing gloves and goggles.

Siegel worries, however, about the risk of contaminated products as some people use the bans as an opportunity to make their own concoctions cheaply and sell them on the black market.

“Who knows what they’re going to put in there?” Siegel said. “This is just what happens when you use prohibition as a regulatory approach. What’s really needed in this situation is actual regulation of these products to try to make them as safe as possible.”

Michigan, Massachusetts, New York, Utah and Rhode Island have passed emergency rules to restrict the sale of e-cigarettes in response to the recent outbreak of vaping-related illnesses, which had sickened 2,051 people and killed 39 as of Nov. 5, according to the Centers for Disease Control and Prevention. In a potentially significant breakthrough, the CDC on Friday said it had identified a link between the mysterious outbreak and vitamin E acetate, an ingredient sometimes added to marijuana-based vaping products.

An additional 220 localities, including San Francisco and Los Angeles County, have passed restrictions on the sale of flavored tobacco products, according to the Campaign for Tobacco Free Kids. Details of an expected federal ban have not been released.

Jones squeezes some of her homemade vape juice into her iridescent purple vape mod.(Heidi de Marco/KHN)

Jones says she has no plans to stop vaping, despite warnings from the Centers for Disease Control and Prevention and mounting evidence that vaping may have serious health risks.(Heidi de Marco/KHN)

Following a rush of new bans in September, a Reddit forum on DIY e-juice saw a spike in membership, the group’s moderator reported. The daily number of new subscribers had long hovered around 30; that number spiked to 336 new subscribers in a single day, followed by more than 200 the next day, and it remained high throughout the month.

The group now has over 52,500 members sharing recipes for flavors such as white chocolate chip cookie, discussing how to make a watermelon that doesn’t taste “soapy,” and asking for tips on how to store supplies safely. Thousands of recipes for e-liquids in myriad flavors can be found in such forums and elsewhere on the internet.

Mike Olson, a resident of Illinois, has stockpiled a multiyear supply of highly concentrated nicotine because he’s so worried about a ban on the sale of flavored vapes. He said he uses gloves and safety goggles while handling it and stores it high up in a closet to keep it away from his dogs.

Not everyone, however, is so scrupulous about safety. A member of the Reddit group, for example, recently posted that he had accidentally sprayed liquid nicotine into his eyes as he tried to remove it from a vial with a syringe. He said his eyes were stinging and turned bright red within a minute, but he washed them out repeatedly. Other members responded with warnings to use protective equipment.

As states, cities and even the federal government consider banning the sale of the e-liquids, vapers like Jones are preparing to make their own liquids at home using social media groups and websites that give detailed instructions.(Heidi de Marco/KHN)

Jones mixes specific artificial flavors, including sweet tart, red licorice and marshmallow to recreate the taste of a Nerds Rope candy in vapor form.(Heidi de Marco/KHN)

Jones holds up the retail version of her favorite vape juice and her homemade version. Making her own e-liquid took her about 15 minutes to make.(Heidi de Marco/KHN)

Poison control centers have received 3,583 calls about exposure to e-cigarette devices and liquid nicotine so far this year, as of Sept. 30, according to the American Association of Poison Control Centers. About 50% of the calls are for children 5 years or younger.

Many of the safety risks of DIY vaping also apply to commercial products. The safety of inhaling food flavorings, for example, has not been established, even in commercially manufactured e-liquids. The Flavor and Extract Manufacturers Association certifies flavored liquids for safety — but only when they are used in food, said John B. Hallagan, a senior adviser to the industry group.

But the U.S. Food and Drug Administration does regulate commercial vaping products to some extent. And while critics say regulation has been inadequate, the agency has nonetheless conducted thousands of inspections of e-cigarette manufacturers and retailers. DIY e-liquids made at home for personal use do not fall under FDA jurisdiction.

Alex Clark, CEO of the Consumer Advocates for Smoke-Free Alternatives Association (CASAA), said he plans to warn the nonprofit’s more than 200,000 members about the dangers of making e-liquid at home.

Clark notes that people should not use flavors found in the baking aisle of a grocery store, such as peppermint oil and lemon extract, because heating and inhaling them can cause lipoid pneumonia, which is potentially life-threatening.

Though a first-time DIY-er, Danielle Jones may have better access than many people to advice on making e-juice safely at home. She works for a company that manufactures the cotton wicking used in vaping devices, sits on the board of CASAA and hosts a YouTube Live show about vaping.

Jones wants to make the process as simple as possible.

Though a first-time DIY-er, Jones may have better access than many people to advice on making e-juice safely at home. She works for a company that manufactures the cotton wicking used in vaping devices, sits on the board of the Consumer Advocates for Smoke-Free Alternatives Association and hosts a YouTube Live show about vaping.(Heidi de Marco/KHN)

She went online to purchase unflavored nicotine that had already been mixed with additives and diluted to her desired concentration. All she needs to do is add the flavors, also purchased online.

“This is complicated,” Jones says, consulting the Nerd Lyfe recipe, which calls for a mix of five flavors: Dragonfruit, Marshmallow, Rainbow Drops, Red Licorice and Sweet and Tart. She opens each bottle and carefully squeezes out a few droplets at a time, her gray hair pulled safely out of her eyes into a loose topknot.

Next comes the nicotine, which resembles a doll-sized plastic jug of gasoline. As she peels off the seal, she gets a little of it on her fingers. But that does not worry her: “This is the same as my commercially available product, and I get that on my fingers all the time.”

The whole process takes Jones about 15 minutes, and the solution is ready to vape. She heads out into her garden, gives the bottle a final shake and squeezes some into her iridescent purple device.

She takes a deep hit, great clouds of vapor billowing out of her nose and mouth. The air smells candy sweet, like inhaling a box of Nerds.

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California Public Health States

Rising Epidemic Of Self-Harm Among Teens Exposes Failures In Psychiatric System’s Treatment Of Behavior

More Adolescents Seek Medical Care For Mental Health Issues

Less than a decade ago, the emergency department at Rady Children’s Hospital in San Diego would see maybe one or two young psychiatric patients per day, said Dr. Benjamin Maxwell, the hospital’s interim director of child and adolescent psychiatry.

Now, it’s not unusual for the emergency room to see 10 psychiatric patients in a day, and sometimes even 20, said Maxwell. “What a lot of times is happening now is kids aren’t getting the care they need, until it gets to the point where it is dangerous,” he said.

ERs throughout California are reporting a sharp increase in adolescents and young adults seeking care for a mental health crisis. In 2018, California ERs treated 84,584 young patients ages 13 to 21 who had a primary diagnosis involving mental health. That is up from 59,705 in 2012, a 42% increase, according to data provided by the Office of Statewide Health Planning and Development.

By comparison, the number of ER encounters among that age group for all other diagnoses grew by just 4% over the same period. And the number of ER encounters involving mental health among all other age groups — everyone except adolescents and young adults — rose by about 18%.

The spike in youth mental health visits corresponds with a recent survey that found that members of “Generation Z” — defined in the survey as people born since 1997 — are more likely than other generations to report their mental health as fair or poor. The 2018 polling, done on behalf of the American Psychological Association, also found that members of Generation Z, along with millennials, are more likely to report receiving treatment for mental health issues.

The trend corresponds with another alarming development, as well: a marked increase in suicides among teens and young adults. About 7.5 of every 100,000 young people ages 13 to 21 in California died by suicide in 2017, up from a rate of 4.9 per 100,000 in 2008, according to the latest figures from the U.S. Centers for Disease Control and Prevention. Nationwide, suicides in that age range rose from 7.2 to 11.3 per 100,000 from 2008 to 2017.

Researchers are studying the causes for the surging reports of mental distress among America’s young people. Many recent theories note that the trend parallels the rise of social media, an ever-present window on peer activities that can exacerbate adolescent insecurities and open new avenues of bullying.

“Even though this generation has been raised with social media, youth are feeling more disconnected, judged, bullied and pressured from their peers,” said Susan Coats, a school psychologist at Baldwin Park Unified School District near Los Angeles.

“Social media: It’s a blessing and it’s a curse,” Coats added. “Social media has brought youth together in a forum where maybe they may have felt isolated before, but it also has undermined interpersonal relationships.”

Members of Generation Z also report significant levels of stress about personal debt, housing instability and hunger, as well as mass shootings and climate change, according to the American Psychological Association survey.

Resources to prevent mental health crisis among youth are often lacking.

“We’re not doing a great job with … catching things before they devolve into broader problems, and we’re not doing a good job with prevention,” said Lishaun Francis, associate director of health collaborations at Children Now, an Oakland-based nonprofit.

Many California school districts don’t have enough school psychologists and don’t devote enough resources to teaching students how to cope with depression, anxiety and other mental health issues, said Coats, who chairs the mental health and crisis consultation committee of the California Association of School Psychologists.

In the broader community, medical providers also are struggling to keep up. “Many times there aren’t psychiatric beds available for kids in our community,” Maxwell said.

Most of the adolescents who come into the emergency room at Rady Children’s Hospital during a mental health crisis are considering suicide, have attempted suicide or have harmed themselves, said Maxwell, who is also the hospital’s medical director of inpatient psychiatry.

These patients are triaged and quickly seen by a social worker. Often, a behavioral health assistant is assigned to sit with the patients throughout their stay.

“Suicidal patients — we don’t want them to be alone at all in a busy emergency department,” Maxwell said. “So that’s a major staffing increase.”

Rady Children’s Hospital plans to open a six-bed, 24-hour psychiatric emergency department in the spring. Improving emergency care will help, Maxwell said, but a better solution would be to intervene with young people before they need an ER.

“The ED surge probably represents a failure of the system at large,” Maxwell said. “They’re ending up in the emergency department because they’re not getting the care they need, when they need it.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Mental Health Multimedia Public Health

Flavor Bans Multiply, But Menthol Continues to Divide

As states and communities rush to ban the sale of flavored tobacco products linked to vaping, Carol McGruder races from town to town, urging officials to include what she calls “the mother lode of all flavors”: menthol.

McGruder, co-chair of the African American Tobacco Control Leadership Council, has tried for years to warn lawmakers that menthol attracts new smokers, especially African Americans. Now that more officials are willing to listen, she wants them to prohibit menthol cigarettes and cigarillos, not just e-cigarette flavors, to reduce smoking among blacks.

McGruder and other tobacco control researchers are using the youth vaping epidemic — and the vaping-related illnesses sweeping the country — as an opportunity to take on menthol cigarettes, even though they are not related to the illnesses.

“We started to see that vaping is something that we could leverage in order to deal with this whole menthol issue,” said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco.

Menthol is a substance found in mint plants that creates a cooling sensation and masks tobacco flavor in both e-cigarettes and cigarettes. Those properties make menthol more appealing to first-time smokers and vapers, even as they pose the same health threats as non-menthol products and may be harder to quit.

Nearly nine out of 10 African American smokers prefer mentholated cigarettes, according to the Centers for Disease Control and Prevention.

But even as tobacco control activists see opportunity, some African Americans, including smokers, fear discrimination. They predict that banning menthol will lead to a surge in illicit sales of cigarettes and result in additional policing in communities that already face tension with law enforcement.

Joseph Paul, director of political and civic affairs at City of Refuge Los Angeles, a church with about 17,000 members in Gardena, Calif., spoke at a board of supervisors meeting in September against a proposed flavor ban in Los Angeles County that was adopted a week later.

If officials truly wanted to end youth vaping, he later told California Healthline, the ordinance should have targeted only vape flavors and exempted adult smokers and their menthol cigarettes.

“Menthol cigarettes are very popular in the black community, my people smoke menthol cigarettes,” he said.

The Los Angeles County ban prohibits sales but not possession of flavored e-cigarette products, menthol cigarettes and chewing tobacco in the unincorporated area of the county, inhabited by about 1 million people. Shops have until April to clear their shelves of flavored tobacco products.

Paul warned that people will start selling menthol cigarettes illegally: “It’s supply and demand.” That will make the community more vulnerable to police harassment, he said.

In New York City, when officials proposed a ban on menthol cigarettes earlier this year, which has yet to be acted upon, the Rev. Al Sharpton made a similar argument against the measure: Banning menthol would lead to greater tensions with police in black communities.

“I think there is an Eric Garner concern here,” the civil right rights activist told The New York Times in July, referring to the well-known case of a 43-year old black man who died in a chokehold in 2014 while being arrested by New York City police on suspicion of selling single cigarettes.

The flavor bans that are currently sweeping the country have more to do with e-cigarettes than menthol cigarettes.

That’s because a mysterious vaping-related illness has sickened more than 2,050 people nationwide and led to at least 39 deaths. In California, at least 150 residents have fallen ill and at least three have died, according to the California Department of Public Health.

Most of those illnesses have been associated with vaping cannabis products, and yet politicians’ urge to adopt flavored tobacco bans continues.

In July 2016, Chicago became the first major U.S. city to ban menthol cigarette sales, but it limited the prohibition to within 500 feet of schools.

Of the more than 200 communities in the country that restrict or ban the sale of flavored tobacco, fewer than 60 include restrictions on menthol cigarettes, according to the Campaign for Tobacco-Free Kids.

Aspen, Colo., will ban all flavored nicotine products, including menthol cigarettes, effective Jan. 1. A few communities in Minnesota already have such bans in place. In California, close to 50 communities restrict or ban flavored tobacco products; of those, more than 30 include restrictions on menthol cigarettes. Notably, San Francisco banned menthol cigarettes along with all flavored tobacco products in 2018, before banning all vapes and e-cigarettes earlier this year.

At the national level, the Food and Drug Administration banned the sale of flavors in combustible cigarettes in 2009, but exempted menthol. Last November, the agency proposed a ban on menthol-flavored combustible cigarettes, calling their use among youths “especially troubling,” but it has not yet taken action.

Then the Trump administration said in September it would soon ban all flavored e-cigarette products, but it may now be backing away from banning mint and menthol.

Menthol, which was first added to cigarettes in the 1920s, is as old-school as it gets when it comes to flavored tobacco, yet it hasn’t prompted action in the way that vape flavors such as cotton candy and strawberry-melon have. That’s because vaping was embraced by a specific population: affluent white teens, Yerger said.

Big Tobacco aggressively pushed menthol cigarettes on black youths in the 1950s and 60s, and now some people consider Kools and Newports part of black culture, McGruder said.

McGruder and others point out that the tobacco industry has supported and funded civil rights groups and causes, forming relationships with prominent black leaders such as Sharpton. Big Tobacco acknowledged that it has contributed to Sharpton’s organization, the National Action Network, and similar groups.

McGruder said it’s difficult for the African American community to contradict respected male civil rights and religious leaders, so when they argue that menthol bans will lead to criminalization, the community listens.

But Bobby Sheffield, a pastor and vice president of the Riverside County Black Chamber of Commerce, said the criminalization argument is a scare tactic.

“We’re not trying to have anyone incarcerated because they have this product in their possession,” Sheffield said. His organization, which represents local businesses, started campaigning this year for menthol bans in California’s Inland Empire, including the cities of Riverside, San Bernardino and Perris.

Some smokers understand the need to keep tobacco out of the hands of children, but they don’t think it’s fair to include menthol cigarettes.

“It’s stupid. Now they’re trying to act like menthol cigarettes are the problem. These have been around for a long time,” said April Macklin of Sacramento, who smokes Benson & Hedges menthols. She smoked when she was younger, quit, and started again three years ago.

The city of Sacramento will ban the sale of flavored tobacco, including menthol cigarettes, effective Jan. 1.

Macklin, 53, said she might just quit because she won’t smoke anything other than menthol. But even with a ban in place, she doubts menthol cigarettes will be gone for good. “I’m sure people will figure something out,” she said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Public Health States

The Air Ambulance Billed More Than His Surgeon Did For A Lung Transplant

THOUSAND OAKS, Calif. — Before his double lung transplant, Tom Saputo thought he had anticipated every possible outcome.

But after the surgery, he wasn’t prepared for the price of the 27-mile air ambulance flight to UCLA Medical Center — which cost more than the lifesaving operation itself.

“When you look at the bills side by side, and you see that the helicopter costs more than the surgeon who does the lung transplant, it’s ridiculous,” said Dana Saputo, Tom’s wife. “I don’t think anybody would believe me if I said that and didn’t show them the evidence.”

“Balance billing,” better known as surprise billing, occurs when a patient receives care from a medical provider outside of his insurance plan’s network, and then the provider bills the patient for the amount insurance didn’t cover. These bills can soar into the tens of thousands of dollars.

Surprise bills hit an estimated 1 in 6 insured Americans after a stay in the hospital. And the air ambulance industry, with its private equity backing, high upfront costs and tendency to remain out-of-network, is among the worst offenders.

Congress is considering legislation aimed at addressing surprise bills and air ambulance charges. And some states, including Wyoming and California, are trying to address the problem even though there are limits to what they can do, since air ambulances are primarily regulated by federal aviation authorities.

That leaves patients vulnerable.

Saputo, 63, was diagnosed in 2016 with idiopathic pulmonary fibrosis, a progressive disease that scars lung tissue and makes it increasingly difficult to breathe.

The retired Thousand Oaks graphic designer got on the list for a double lung transplant at UCLA and started the preapproval process with his insurance company, Anthem Blue Cross, should organs become available.

Tom and Dana Saputo used to wheel out a bar cart for parties. Now the table is a permanent fixture in their kitchen, where Tom keeps more than a dozen bottles of supplements and anti-rejection medications. (Anna Almendrala/KHN)

But before that happened, he suddenly stopped breathing on the evening of July 7, 2018. His wife called 911.

A ground ambulance drove the couple to Los Robles Regional Medical Center, 15 minutes from their house, where Saputo spent four days in the intensive care unit before his doctors sent him to UCLA via air ambulance.

He was on the brink of death, but just in time, the hospital received a pair of donor lungs. They were a perfect match, and two days after arriving at UCLA, Saputo was breathing normally again.

“It was a miracle,” he said.

Saputo’s recovery was difficult, and problems like infections put him back in the hospital for observation. But the most unexpected setback was financial.

When Saputo opened a letter from Anthem, he discovered the helicopter company, which was out of his network, had charged the insurance company $51,282 for the flight, and Saputo was responsible for the portion his insurance didn’t cover: $11,524.79.

By contrast, the charges from the day of his transplant surgery totaled $40,575 — including $31,605 for his surgeon — and were fully covered by Anthem.

Saputo appealed to Anthem twice about the ambulance charges. Meanwhile, the helicopter company, Mercy Air, kept calling him after he left the hospital, asking him to negotiate with his insurance company. It even called his adult daughter in San Francisco to ask how the Saputos planned to pay the bill.

“I have no idea how they even got her name or her number,” Saputo said.

Mercy Air is a subsidiary of Air Methods, which operates in 48 states and is owned by the private equity firm American Securities.

Air Methods acknowledged via email that it had put Saputo through a “long and arduous process.” The company contacted his daughter because it tried every phone number associated with him, said company spokesman Doug Flanders. But Air Methods laid the blame at the feet of his insurer.

Anthem spokeswoman Leslie Porras said the blame doesn’t lie with insurers, but with air ambulance companies that remain out of network so they can charge patients “whatever they choose.”

“The ability to bill the consumer for the balance provides little incentive for some air ambulance providers to contract with us,” Porras said.

(In January, six months after Saputo’s surgery, Anthem entered into a contract with the air ambulance company to make it an in-network provider, she said.)

Air Methods forgave Saputo’s bill in August after ABC’s “Good Morning America,” working with Kaiser Health News, inquired about his case. Air Methods said it was an internal decision to zero out his bill.

The Saputos sit in their backyard with their three dogs, Lindsey, Owen and Beatrice. (Anna Almendrala/KHN)

Other patients usually aren’t as lucky.

The median cost of a helicopter air ambulance flight was $36,400 in 2017, an increase of more than 60% from the median price in 2012, according to a Government Accountability Office analysis. Two-thirds of the flights in 2017 were out-of-network, the report found.

The air ambulance industry justifies these charges by pointing out that the bulk of its business — transporting patients covered by the public insurance programs Medicare and Medicaid — is severely underfunded by the government.

The median cost to transport a Medicare patient by air ambulance is about $10,200, according to an industry study. However, air ambulance companies are reimbursed a median rate of $6,500 per flight.

“The remaining 30% of patients with private health insurance end up paying over 70% of the costs,” said Flanders of Air Methods.

But critics argue the real problem is market saturation. While the number of air ambulance helicopters in the U.S. has increased — rising more than 10% from 2010 to 2014 — the number of flights hasn’t, which means air ambulance companies seek to raise prices on each ride.

“This is a great opportunity to make money because patients don’t ask for the price before they receive the service,” said Ge Bai, an associate professor of accounting and health policy at Johns Hopkins University.

That’s what frustrated the Saputos the most about their air ambulance charge: There was no way they could have shopped around to compare costs beforehand.

“There’s just no possible way that a customer of insurance can navigate that process,” Dana Saputo said.

Bai also criticized the practice of charging privately insured patients exorbitant amounts to make up for losses from Medicaid and Medicare patients and keep the air ambulance industry afloat.

“If they feel that Medicare and Medicaid is paying too little, they should lobby the government to get a higher reimbursement,” Bai said.

In California, Democratic Gov. Gavin Newsom signed a bill in early October that will limit how much some privately insured patients will pay for air ambulance rides. Effective next year, AB-651, by state Assemblyman Tim Grayson (D-Concord), will cap out-of-pocket costs at patients’ in-network amounts, even if the air ambulance company is out of network.

A more novel scheme in Wyoming would treat the industry like a public utility, allowing the state’s Medicaid program to cover all of its residents’ air ambulance trips and then bill patients’ health insurance plans. The state would then cap out-of-pocket costs at 2% of the patient’s income or $5,000, whichever is less. Wyoming needs permission from the federal government to proceed.

Ultimately, though, state authority is limited because the federal Airline Deregulation Act of 1978 prohibits states from enacting price laws on air carriers.

Congress is considering several bipartisan bills on surprise billing. One measure by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would ban balance bills from air ambulance companies. The bill passed committee and is now headed to the Senate floor for a vote, pending approval from Senate Majority Leader Mitch McConnell.

Air Methods said that, in general, it would support federal legislation that would calculate new rates for Medicare reimbursement, as long as they are based on cost data the industry provides.

But there is intense industry opposition to the bill. Combined with the complexity of the legislation (it also includes prescription drug price reform) and competing Senate leadership priorities, the measure faces a rocky path to the president’s desk, said Melissa Lorenzo Williams, manager of health care policy and advocacy at the National Patient Advocate Foundation.

“Despite having bipartisan and bicameral support, I can’t confidently say that this is something that will pass,” Williams said.

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California Cost and Quality Health Care Costs States

California Air Quality: Mapping The Progress

Ed Avol grew up in Los Angeles in the 1960s, but he rarely caught a glimpse of the rolling green contours and snowy peaks of the San Gabriel Mountains just east of the city. More often than not, they were obscured by the low-hanging gauze of smog that cloaked the L.A. basin in a dreary gray much of the year.

“Most days you could not see the mountains” said Avol, now a professor of clinical preventive medicine at the University of Southern California’s Keck School of Medicine and chief of its environmental health division. “I was amazed that there were even mountains there.”

The effects of the smog weren’t just visual; they were felt by residents living in that polluted air. Persistent headaches. Watering eyes. Labored breath. Avol recalls how he and other members of his high school cross-country team sometimes coughed for days after competing in the smoggy air.

Over the decades, Avol has continued to make his home in Los Angeles, and has had a front-row seat to dramatic improvements in air quality. Much of that improvement stems from the ever-tightening standards California has enacted for auto and truck tailpipe emissions, starting in the 1960s. Avol is among the environmental researchers whose work has helped propel that steady progress.

“There’s a significant air pollution problem in California,” Avol said. “There’s also a success story to tell for pollution mitigation and reduction in California.”

California is now engaged in a high-stakes legal battle with President Donald Trump and his administration over the state’s longstanding authority to set its own emissions standards for cars and trucks sold in California. The administration has moved to revoke a waiver, in place since the federal Clean Air Act of 1970, that enables the state to set stricter emissions standards than the federal government because its pollution problems are so unique and severe.

In its initial efforts, California’s stricter standards targeted the emissions that fed the cloak of smog Avol knew growing up, including ozone and carbon monoxide. More recently, the state has expanded its target to include greenhouse gas emissions that contribute to climate change and global warming.

When it comes to smog, the standards have made a difference. Over the past three decades, counties across the state have made steady progress in reducing days that registered hazardous levels of ozone and particulate matter.

The improved air quality led to improved health indicators. For example, a recent USC study that tracked Southern California children over 20 years found that the reduction in smog translated to roughly 20% fewer new asthma cases in children.

Even with progress, the state’s pollution problems are far from solved. California’s large population combined with its fanatic car culture, warm climate, wind patterns and towering mountain-to-deep-valley geology have made continued improvement challenging. The state also bears a disproportionate burden of the country’s economic trade via high-emission trains, planes and ships.

California still has the five metropolitan areas that routinely register the highest levels of ozone pollution in the nation: Los Angeles, Visalia, Bakersfield, Fresno and Sacramento.

Avol is among those who say the Trump administration’s efforts to roll back emissions standards are likely to impede further progress. Still, he finds a silver lining. The standoff has focused a spotlight on how far California has come because it implemented strict standards and the difference that has made for the people who live here.

“In terms of protecting public health,” Avol said, “improving air quality is a big deal.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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For Young People With Psychosis, Early Intervention Is Crucial

Andrew Echeguren, 26, had his first psychotic episode when he was 15. He was working as an assistant coach at a summer soccer camp for kids when the lyrics coming out of his iPod suddenly morphed into racist and homophobic slurs, telling him to harm others — and himself.

Echeguren fled the soccer camp and ran home, terrified the police were on his heels.

He tried to explain to his mom what was happening, but the words wouldn’t come out right. His parents rushed him to a children’s crisis center, where an ambulance arrived and transported him to the adolescent psychiatric facility at St. Mary’s Medical Center in San Francisco.

“I thought it was a joke,” Echeguren said. “I didn’t think it was really happening because I didn’t know what was real or not.”

Echeguren received antipsychotic medication, was put in a quiet room and looked after by attentive caregivers who helped stabilize him.

Many young people don’t get the care they need so rapidly after a psychotic episode, if at all. As a result, they can become chronically disabled, and some end up homeless, incarcerated or addicted to drugs.

“Early intervention preserves the most important pieces of a young person’s life — relationships with family and friends, success at work or school,” said Tara Niendam, executive director of Early Psychosis Programs at the University of California-Davis.

Research corroborates Niendam’s view, and California lawmakers have endorsed it: The California state budget signed earlier this year by Gov. Gavin Newsom provides $20 million to create early intervention programs and expand existing ones.

Only about half of the state’s 58 counties have such a program, and many of those that do struggle to keep them open because of a lack of funding and a limited pool of trained behavioral workers.

Nationally, the median time between the first symptoms of psychosis and the start of treatment is nearly a year and half, according to a study by the National Institute of Mental Health. That is six times longer than the World Health Organization’s recommendation of three months or less.

Each year, an estimated 8,000 adolescents and young adults in California experience their first psychotic episode, according to Thomas Insel, Newsom’s mental health adviser. Insel extrapolated that number from data showing that every year about 100,000 young people nationwide experience their first psychotic episode.

Psychosis refers to a group of mental disorders, such as schizophrenia, that cause people to lose contact with reality. The average life span of people with major mental illnesses is up to 32 years less than for the general population, largely because they are at greater risk for multiple chronic diseases.

“These people don’t live beyond their late 50s,” said Insel, a former director of the National Institute of Mental Health. “It’s not a pretty picture. It’s a sad statement of where we are in the way we treat this illness.”

Mental health experts say the most effective early psychosis treatment is something known as coordinated specialty care, which incorporates medication and psychotherapy with case management, support groups for the patients’ families and assistance securing employment or education.

Experts say there is significant momentum nationally for expanding and improving early psychosis treatment.

The big question is how to implement a strategy across California, said Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, the state agency tasked with ensuring that the early psychosis funding is spent effectively.

It will look to early psychosis models in Oregon and New York, which are ahead of California in statewide coordinated specialty care clinics, Ewing said. California will also partner with the federal government on a strategy for developing coordinated specialty care models nationally, he said.

But there’s a complication: Unlike other states that have centralized mental health care systems, in California it is up to each county to decide whether to provide early psychosis services or not. Patients who live in counties without such services often must drive long distances to find a clinic that provides the specialized care they need.

Another barrier to access is insurance. “We have a disjointed financial system that impacts an individual’s ability just to walk in the door of a program,” said Niendam, who operates two early psychosis clinics in Northern California. One of them accepts private insurance and self-pay; the other is for patients who are uninsured or on Medi-Cal, the state’s Medicaid program.

Niendam said she can bill Medi-Cal for a greater number of services than she can private insurers, including at-home support for patients who are too sick to come to the clinic; family and patient advocacy; and education and employment support.

Echeguren, who was able to get adequate care on his parents’ relatively generous health plan, said that after several days in the St. Mary’s psych unit, the frightening auditory hallucinations that had sent him running from the soccer camp began to fade. “It felt good,” he said. “I felt like I had narrowly escaped disaster.”

After he left the hospital, Echeguren saw a psychiatrist and enrolled in a program called Prevention and Recovery in Early Psychosis, which connected him to a therapist and family groups that he and his parents attended.

Ultimately, Echeguren graduated from high school, and then college. He now works at a public relations firm in San Francisco and lives with his girlfriend.

He knows how lucky he is to have benefited from such rapid intervention.

“If I would have waited a year and a half for treatment, I would be dead,” he said. “I would have done something bad to myself.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Sweetgreen Makes Healthful Fast Food — But Can You Afford It?


Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.


At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.


Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.


Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”