Tagged Health Care Costs

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! We have officially made it through the dog days of summer. (Fun fact: Apparently those are set dates and not just … a vague concept of “sometime in August when it’s hot.” I was today-years-old when I learned that.) But that doesn’t mean we’ve had even close to a dearth of health care news. So buckle up, here’s what you may have missed this week.

Planned Parenthood officially rejected Title X funding rather than comply with what it deemed a “gag rule” on its providers. The price tag on that decision? About $60 million annually. Clinics across the country are bracing for the financial hit, and the organization is leaning heavily on donors to try to stanch the wound.

The New York Times: Planned Parenthood Refuses Federal Funds Over Abortion Restrictions

The Associated Press: Planned Parenthood Sees Swift Fallout From Quitting Program


Meanwhile, it was a bit of a roller-coaster week in terms of whether President Donald Trump would be pushing for background checks in his proposal to stem gun violence. After the dual mass shootings in El Paso, Texas, and Dayton, Ohio, Trump seemed open to the strategy, despite it being less than popular with his party. Then The Atlantic reported that following a phone call with NRA chief Wayne LaPierre, Trump softened that stance. Then Trump claimed the media reports were inaccurate and that some kinds of background checks were still on the table.

Pretty much nothing seems set in stone yet (at least publicly), and we should all just wait to see what comes in the official proposal likely to coincide with Congress’ return in September.

The Atlantic: Trump’s Phone Calls With Wayne LaPierre Reveal NRA’s Influence

Politico: Trump to Release Gun Control Proposals, Including Background Check Updates

We did find out this week exactly what was in the Parkland students’ plan, though. And let me tell you, they swung for the fences with it. Included in the roadmap: a national licensing and gun registry; a mandatory gun buyback program for assault-style weapons; a limit of one firearm purchase a month per person; the establishment of a national director of gun violence prevention; and a new multistep gun licensing system that would include in-person interviews and a 10-day waiting period before gun purchases are approved.

USA Today: Parkland Students Announce Gun Control Plan, Aim to Halve Gun Violence Rate in 10 Years


The Trump administration (and the Obama administration, as well) has long chafed at the restrictions that come with the Flores Settlement Agreement, which offers protection to detained immigrant children in U.S. custody. So, this week it released a new set of rules that effectively replace those regulations. Among other things, the new standards allow the government to detain children indefinitely instead of for 20 days, as laid out in the Flores agreement.

Reuters: Trump Imposes Rule Allowing U.S. to Detain Migrant Families Indefinitely

What’s definitely worth a read: the history behind the agreement and the story of the lawyers who have been defending it for decades. (“If someone had told me in 1985 that our work to protect children would continue into 2019, there is no way I would have believed it,” says Carlos Holguin, one of those original lawyers.)

The New York Times: The Flores Agreement Protected Migrant Children for Decades. It’s Under Threat.


Thirteen years ago, then-U.S. Surgeon General Richard Carmona was warned about some “disturbing” data that top federal scientists had discovered. It turned out that opioids were addictive and dangerous. The scientists recommended urgent action be taken to address the startling statistics, which hinted at a brewing crisis. Carmona agreed.

Yet the public was never told, and the momentum to do so fizzled. So what happened?

Politico: Federal Scientists Warned of Coming Opioid Crisis in 2006

Seemingly to further emphasize that the opioid epidemic’s early days were marked by (in retrospect) devastating missed opportunities and deep regret, another story looks at a little town in Appalachia in the late 1990s. There, a nun, a doctor and a lawyer were among the nation’s first activists to sound the alarm. Their efforts were ultimately crushed by Purdue Pharma.

The New York Times: A Nun, a Doctor and a Lawyer — and Deep Regret Over the Nation’s Handling of Opioids

Meanwhile, a study links states’ expansion of Medicaid and the uptick of opioid treatment prescription rates.

The New York Times: Opioid Treatment Is Used Vastly More in States That Expanded Medicaid

And HHS is going to relax privacy regulations around how patients’ history with addiction is noted in their charts. The rules were put in place so that patients felt comfortable seeking medical help without law enforcement being alerted, but HHS Secretary Alex Azar said they’ve become a barrier to proper care.

The Associated Press: Feds to Revamp Confidentiality Rules for Addiction Treatment


The FDA is stepping in to join the CDC’s investigation into cases of lung disease across the country that seem linked to vaping.

The New York Times: Vaping Sicknesses Rising: 153 Cases Reported in 16 States

And don’t miss the story from KHN’s own Victoria Knight about a West Virginia physician who all the way back in 2015 filed a paper on a patient with a lung disease he suspected was tied to vaping.

Years Ago, This Doctor Linked a Mysterious Lung Disease to Vaping


In this week’s miscellaneous file:

  • Emergency care in financially depressed areas has become a standoff between insolvent rural hospitals and patients who don’t have the money to pay their ER bills. That fight is ending up in court so often that locals in a small Missouri town call it the “follow-up appointment.”

The Washington Post: The ‘Follow-Up Appointment’

  • One of the side effects of the growing popularity of at-home DNA tests? More and more, people who were born using artificial insemination are finding out that their fathers aren’t the sperm donors their mothers chose but rather the doctor who performed the procedure.

The New York Times: Their Mothers Chose Donor Sperm. The Doctors Used Their Own.

Also, be sure to check out the Dallas Morning News’ original reporting from April on one of the women featured in the story.

Dallas Morning News: ABC’s ’20/20′ Features Dallas Woman Who Found Out Her Mother’s Fertility Doctor Is Her Father

  • The patient suffers from tremors, difficulty walking and loss of balance. If the patient is a man, his symptoms would be enough to have doctors start wondering if it’s Parkinson’s. But if it’s a woman, it’s chalked up to the modern-day version of what Victorians called female “hysteria.”

ProPublica: In Men, It’s Parkinson’s. In Women, It’s Hysteria.

  • For years, residents of a Newark neighborhood have been saying their water tastes funny because of the dangerous levels of lead. And yet little has been done to fix it.

The New York Times: ‘Tasting Funny for Years’: Lead in the Water and a City in Crisis


That’s it for me, and have a great weekend!

Readers And Tweeters Take Dialysis Providers To Task: Nowhere But In The USA

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


The Undue Strain Of Dialysis

This is criminal, and the dialysis companies are not the only ones plundering the public (“Bill Of The Month: First Kidney Failure, Then A $540,842 Bill For Dialysis,” July 25). If you have no medical insurance and go to a doctor or hospital for medical care, you get charged tenfold what they accept from insurance companies. No properly run health care facility or doctor is losing money by accepting the agreed fees that the insurance companies pay. It’s absolutely outrageous to charge people who can least afford to pay up to 10 times the insurance charges. This scam has existed for decades and Congress has done nothing to protect consumers. My understanding is that no other country allows this discrimination against the poor. It’s time this outrageous exploitation of consumers be terminated.

— Jorg Meister, Middlegrove, N.Y.


— David W.S. Lieberman, Somerville, Mass.


This is in response to the bill of Sovereign and Jessica Valentine. It is ridiculous that Fresenius can charge them $14,000 per session when dialysis in Mexico using the same dialysis machines and procedures runs $400 USD per session. I take my mother there frequently for vacation, and we pay cash for her dialysis sessions.

—Martina Patella, Oakland, Calif.


— Andrea Hilderman, Manitoba, Canada


I was appalled to read your article on dialysis. I have a dear friend who built, opened and now operates a dialysis center in Thessaloniki, Greece. His father is a kidney specialist of 30+ years. He wrote the string below about dialysis in Greece when I forwarded the story to him:

“If you have insurance dialysis is free
Zero
Gratis
The average price that dialysis facilities in Greece charge the Greek NHS is around 136 euros.

If a patient who does not have insurance goes to a dialysis facility, he will be charged around 200 euros [about $223 in the United States]. That will be a great day for the facility.”

— Jerry Efremides, New York City


PBMs Put Patients In A Pickle

Besides the delay of generic drugs to market (“California Bill Would Fight Deals That Delay Generic Drugs,” Aug. 1), the pharmacy benefit managers (PBMs) have deals with the manufacturers, and pharmacies are not allowed to dispense a new generic because the PBM will not allow it to happen. Currently, there are Medicare plans that will not pay for generic Ventolin or Advair and demand that we dispense the brand name. It costs patients more, the plan more, and pharmacies lose by dispensing the brand-name drugs.

— David Smith, A & O Clinic Pharmacy, Salinas, Calif.


Winning The Match Game

This is not news (“American Medical Students Less Likely To Choose To Become Primary Care Doctors,” July 3). Medical students have been choosing the higher-end specialties over primary care for decades. I have been in the health care industry for over 40 years and have worked with literally thousands of physicians as an executive at Cedars-Sinai Medical Center and at my two companies, Practice Management Information Corp. and Flash Code Solutions LLC. My daughter and her husband are both radiation oncologists. Board certification in a higher specialty results in higher income and better career choices. Why settle for family practice if you can be an orthopedic surgeon?

— James B. Davis, president and CEO of Practice Management Information Corp., Beverly Hills, Calif.


— Dr. Jacqueline Ivey-Brown, Chicago


Meds And Momentary Mental Lapses

I read your Navigating Aging column about how many medications affect older adults (“Common Medications Can Masquerade As Dementia In Seniors,” July 18). I am 85 and had two knee replacement surgeries. Every time I have to go to the dentist, I must take four amoxicillin antibiotic tablets one hour before the dentist appointment. I noticed that after I took these antibiotics, my memory became very bad. After a few days, I felt like myself again.

— Janet Gileno, Bomoseen, Vt.


— Dr. James P. Richardson, Baltimore


Weighing Costs And Benefits Of Intravenous Iron

I feel your article about iron infusions (“Infusion Treatments — Needed or Not — Can Deplete Patients’ Wallets” Aug. 2) was biased. The article did not discuss the reasons a physician might choose to use IV iron to treat a patient versus oral iron – oral iron is not well tolerated and in the presence of inflammation in the body is not well absorbed. There are blood management programs in the United States that regularly use IV iron to treat anemia to decrease the patient’s risk for a blood transfusion. Although the cost of IV iron differs from one drug to another (the less expensive drugs, such as Ferrlecit, require multiple infusions), when you add up the cost, it includes not only the administration of the drug, but the nursing time and pharmacy preparation time for the medication.

One also must consider the risk for reaction when choosing a particular form of IV iron. Anaphylactic reactions can occur in patients receiving IV iron. Injectafer is one of the drugs we use on a regular basis because other forms of IV iron have a greater risk for reaction. One must consider the added cost of treating an anaphylactic reaction in a patient. Injectafer is a longer-acting form of IV iron; slow-release preparations such as ferric carboxymaltose (Injectafer) are first taken up by macrophages, the shell is digested, and the iron is released slowly over few days as opposed to near-immediate iron release found in other preparations that lead to more adverse reactions.

Although your story provided the experience of a single patient, it did not report the “whole” story about why physicians use IV iron. I receive no incentive for using one drug over another and must consider the patient’s clinical condition and the risks associated with giving IV iron. IV iron will correct iron levels more rapidly in patients because you can give a higher concentration of the drug, versus oral iron, which can take upward of a couple months to improve iron levels. Without really knowing the physician’s rationale for using IV iron in the case of the patient in the article, the author drew conclusions without having all the facts. I agree that we really need to look at health care costs, but the author of the article also failed to mention Big Pharma’s role in driving up the cost of health care.

— David J. Sterken, Grand Rapids, Mich.


— Jim McMullen, Kansas City. Mo.


As a Board Certified Oncology Pharmacist (BCOP), hematology/oncology is my field. Our institution used the cheaper iron (Venofer, which, at a low dose of 100 mg, needs to be given more often) for years. Medicare stopped paying for it because the charge was less than $100 — for some reason, the federal insurance program will not bother to pay for lower-cost IV drugs. Seriously. We switched our formulary iron to Injectafer, 750 mg per vial (cost to us ~$100-$750/vial, and the charge to patients per vial is about $1,000 and up), because we were reimbursed by Medicare for the Injectafer (because it is more than $100).

You are spot-on: The USA does not give our healthy iron-deficient patients enough time to benefit from oral iron. We inject IV iron for iron-deficiency anemia even when the patient does not suffer from anything other than bad lab tests.

Most hospitals and ambulatory care centers base their formulary decisions in large part on reimbursement. Medicare cannot bid for drug pricing and does not have a national formulary. This is a serious error on the part of the legislature and costs billions of dollars or more in taxpayer money that goes directly into the pocket of the pharmaceutical industry. Not paying for lower-cost IV drugs is just one very small example. It is terrible for the patients who must bear the cost of this discrepancy.

Reimbursement is a complex issue these days in no small part to the waste of the government.

— Mary Davis, Bellingham, Wash.


— Dr. Nicolas Argy, Boston


Shefali Luthra’s article on intravenous iron is rife with error. The pricing is not close, relative costs are wrong, and the implication of inappropriate use may be correct only based on utterly usurious prices listed.

More than 70% of those prescribed oral iron (PO) report significant gastrointestinal (GI) perturbation, intolerance and non-adherence. PO iron causes diarrhea and constipation, gastric cramping, metallic taste and thick, green tenacious stool. A year of therapy is required to replace stores and correct hemoglobin concentrations, all of which can be done with IV iron in 30 minutes. For people with hereditary bleeding disorders, there is zero credible expectation oral iron can keep up with losses since 10% (maximum) of PO is absorbed and PO raises a protein, hepcidin, which blocks iron absorption for 24 to 48 hours, making adequate repletion unrealistic.

InjectaFer is the most expensive iron. It costs $843 for 750 milligrams. Based on the preponderance of published evidence, a gram of iron in a single dose is about all we can utilize. The recommended dose of InjectaFer is 1,500 mg, $1,686 for a course (not vial) of iron. I think that wastes 500 mg, and there is double-blind, prospective evidence supporting that conclusion. It costs $100 for an office visit, chair time nursing and IVs, which takes 15 minutes. If you visit twice, that’s an additional $100.The charges you mentioned suggest that an institution in New York is fleecing its clients or insurance companies. This is usury and should be investigated and stopped.

The health economist Richard Pollock is mistaken. IV iron is widely used in Great Britain and it is extremely likely, not unlikely, a patient with chronic blood loss would get IV iron, irrespective of symptoms. That being said, Ferinject, the European name for InjectaFer, costs $140 per gram and health providers don’t have to deal with the ridiculous 750 mg vial we do. Feraheme costs $466 for 510 mg and requires two vials for a gram (1,020 mg). Four insurers allow me to give 1,020 mg in a single 30-minute infusion: the Blues, MedStar, Priority Partners and Cigna. The rest, including Medicare and Medicaid, require two visits. The only benefit is to our practice, which gets $100 for the completely unnecessary second visit. Despite making it clear the single 1,020 mg infusion is just as safe and effective, you halve the number of IVs and chances for minor reactions. It’s not covered, I have no choice. A third get it once; two-thirds, twice. We charge $932 plus a 6% markup to cover nursing costs and paraphernalia.

INFeD, or low molecular weight iron dextran, costs $243 per gram, comes as 100 mg vials and requires 10 vials for 1 gram. It takes an hour and is just as safe and efficacious.

The author is mistaken about Venofer, iron sucrose and Ferrlecit, ferric gluconate. You can’t give more than 200-250 mg because the sugar that carries iron does so much less tightly than the carbohydrate cores of InjectaFer, Feraheme and INFeD. To give a gram takes four to five visits. I never use these drugs for that reason, but I have no criticism of nephrologists who use them in dialysis with thrice-weekly visits. Venofer is $600 per gram (definitely more than INFeD) and Ferrlecit $1,000 per gram.

The medical system you wrote is screwing the community. IV iron is an unmet need. Oral iron cannot keep up with losses in abnormal uterine bleeding, be absorbed after bariatric surgery, makes inflammatory bowel disease worse because it is directly toxic to the intestinal epithelium and makes the wrong bacteria grow, and most of all doesn’t get to babies in the third trimester when the fetal brain needs iron for normal development. IV iron is a godsend for millions.

— Dr. Michael Auerbach, Baltimore


Correct By Degrees

The article “‘Climate Grief’: Fears About The Planet’s Future Weigh On Americans’ Mental Health” (July 18) said a recent report by the Intergovernmental Panel on Climate Change predicts that “by 2040 the Earth will warm by 2.7 degrees Fahrenheit (1.5 degrees Celsius).” As the report’s opening page (to which you link) says, by 2040 the Earth will have warmed by 2.7F above preindustrial levels. That’s total warming over 200 years, not future warming in the next 22 years.

The report also provides little support for the extreme claims that have terrified so many people — and, even less excusably, terrified so many children. This is also true of many reports by the major climate agencies.

The IPCC is the largest and best-run project of its kind, ever — an assessment of current science, which is then summarized for non-scientists. The tragedy is that its work has been largely abandoned for propaganda that exaggerates or even ignores the findings. I believe this has caused the gridlock in U.S. climate policy, so that we are not only unprepared for future extreme weather, but for the inevitable repeat of past extreme weather.

— Larry Kummer, editor of the Fabius Maximus website, Davenport, Iowa

Editor’s note: Warm thanks for pointing out the error. Our article has been updated.


— Michelle Mills, Chicago

— James C. Coyne, Philadelphia


Incrementally Exploited By Politicians

My copay requirement of $7,500 plus a monthly payment must be paid before my insurance pays any expenses. This is not health care. On paper I have health care; but the reality is I can’t afford to use it. It simply would stop me from bankruptcy in case of an emergency. However, these politicians and attorneys are making millions and getting a lot of publicity with every petition they file (“Biden’s ‘Incremental’ Health Plan Still Would Be A Heavy Lift,” July 22).

I feel the politicians should have the same health care choices as the American people. This would help them make better choices. Democrats and Republicans know health care in the U.S. is unaffordable. They should all be fired for not doing their job.

I also believe they should be able to serve only two terms, just like the presidential office. Politicians treat their position as a lifestyle instead of a job.

— Catherine Mossner, Gladwin, Mich.


The Battle For Uniform Excellence In Tribal Care

I’m part Inupiaq Eskimo from northwestern Arctic Alaska. The article “How The Eastern Cherokee Took Control Of Their Health Care”(July 22) states that the Cherokee benchmarked a program developed by Southcentral Foundation, a Tribal Health Organization originally created by an ANCSA (Alaska Native Claims Settlement Act) corporation but allowed to operate as a Public Law 93-638 entity. Awarded largely no-bid contracts through the Indian Health Service, Southcentral Foundation legally represents only shareholders of Cook Inlet Region Inc. — not all Alaska Native peoples.

To say SCF and other Alaska Natives run the program may be partly accurate, but it does not give credit to valuable contributors who served for decades ensuring we understood and implemented programs designed for all cultures — even families related to non-Indian Health Service beneficiaries.

Augusta Reimer is one of those deserving credit for this program. She was the first female Alaska Native/American Indian chief of an Indian Health Service department and was largely responsible for creating an atmosphere of wellness and creativity. Reimer, from IHS, and Mike McKeown from the University of Alaska-Anchorage designed my degree in human services; she spent hours working with interns and volunteers educating them on laws impacting us. Everyone who contributed deserves to be cited accurately and not just in a side note as other “Alaska Natives.”

The government has been pretty decent about encouraging native peoples’ self-determination, but it does not come without responsibility to follow the standards of care and communication and the law to ensure the quality and longevity of our programs.

The Indian Health Service was not approved to provide care to non-Indian health service beneficiaries. So the Nuka system of care — originally called Nutuqsiivik, which means “new beginnings” — was created to help identify gaps in data that were barriers to providing care to families with multiple health care providers and health and socioeconomic issues.

Indian Health Service programs have come a long way, but consistency and uniformity among tribal areas is highly concerning. In the age of a one-payer review, transparency is critically important. So is accuracy. Data and the lack thereof can cause a myriad of health and economic issues the patient or customer may have to deal with while their tribal organization isn’t monitored or corrected when needed. Without competition, I fear, these programs do not adequately respect patient needs, desires and have no real incentive to improve the quality of their care in order to keep their customers.

The Alaska legislature has created a committee specifically designed to educate lawmakers and the public on issues affecting the public and the tribes because there are so many of us. These programs do not live in a vacuum, but rather impact local economic development and regulatory control over your community. I encourage accountability among all parties and the mirroring of the U.S. Constitution and laws, so we have a legal template to follow.

— Cheryl Bowie, Anchorage, Alaska

Dialysis Industry Spends Big To Protect Profits

The dialysis industry spent about $2.5 million in California on lobbying and campaign contributions in the first half of this year in its ongoing battle to thwart regulation, according to a California Healthline analysis of campaign finance reports filed with the state.

Last year, dialysis companies poured a record-breaking $111 million into a campaign to defeat a ballot initiative that would have capped their profits.

This year’s political spending, which includes an online and broadcast advertising blitz, is aimed at killing a bill in the state legislature that would disrupt the industry’s business model — and likely reduce its profits. The dialysis industry counters that the bill would threaten some low-income patients’ access to the lifesaving treatment.

“Nobody is spending $2.5 million out of the goodness of their hearts,” said David Vance, a spokesman for Common Cause, a nonprofit group that advocates for campaign finance reform. “That kind of money is spent to get the attention of legislators and to get results.”

And the spending doesn’t appear to be slowing. Since the most recent campaign finance reporting deadline, which showed a total of $2.5 million spent through June, a campaign committee backed by the industry has spent at least $470,000 more since then.

Dialysis filters the blood of people whose kidneys are no longer doing the job. People on dialysis, who typically need three treatments a week, usually qualify for Medicare, the federal health insurance program for people 65 and older, and those with kidney failure and certain disabilities.

But dialysis companies can get higher reimbursements from private insurers than from Medicare. One way dialysis patients remain on private insurance is by getting financial assistance from the American Kidney Fund, which helps nearly 75,000 low-income dialysis patients, including about 3,700 in California.

The American Kidney Fund receives most of its donations from DaVita Inc. and Fresenius Medical Care, the two largest dialysis companies. The fund does not disclose its donors, but an audit of its finances reveals that 82% of its annual funding in 2018 — nearly $250 million — came from two companies.

Critics of this system, including some California lawmakers, insurance companies and a powerful nurses union, say it’s a way for the dialysis industry to inflate profits by steering patients away from Medicare and other public insurance coverage to private insurance, which pays higher rates.

The measure under consideration in the legislature, AB-290 by state Assemblyman Jim Wood (D-Santa Rosa), would limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund. The bill would also address a similar dynamic in drug treatment programs.

“The minute you try to close one of those loopholes, the folks involved spend millions and millions to fight you,” Wood said.

The state Assembly approved the bill in May, and the state Senate is now considering it. The legislature passed a similar measure last year that former Gov. Jerry Brown vetoed, saying the language was too broad and the move would have allowed providers to refuse care to some patients.

DaVita and Fresenius declined to comment and directed questions to Kathy Fairbanks, spokeswoman for the “Dialysis is Life Support” coalition, which includes dialysis providers, industry groups, patients and caregivers. She said the dialysis industry isn’t the only stakeholder trying to influence the political process.

Groups supporting the measure, including large insurance companies and labor unions, also are spending big, she said. For instance, a committee formed and funded by the Service Employees International Union-United Healthcare Workers West to support last year’s initiative — and challenge the dialysis industry and its profits — spent $580,000 in the first half of this year.

The $2.5 million in political spending by the dialysis industry between January and June falls into two categories: lobbying the legislature, and campaign contributions to support candidates and influence public opinion. Campaign spending made up about $1.3 million of the total.

DaVita accounted for the biggest chunk of the campaign spending: $580,000. Fresenius spent $270,000.

These contributions went to 48 of the state’s 80 Assembly members and 21 of the state’s 40 senators, primarily to their prospective 2020 or 2022 campaigns.

Of the 69 legislators who received money from DaVita and Fresenius, Assemblyman James Ramos (D-Highland) got the most: $16,800 in the first half of the year. Ramos did not respond to requests for comment.

Nine other Assembly members and two senators each also received more than $10,000 in contributions from DaVita and Fresenius.

The rest of the $1.3 million in campaign spending was doled out by the campaign committee formed and funded by the industry to defeat Proposition 8 last year. The “Patients and Caregivers to protect dialysis patients” committee spent $440,000 in the first half of 2019, mostly on an advertising campaign to sway public opinion against Wood’s measure.

The media campaign began by promoting the message “Dialysis is Life Support” via social media accounts and a slick website, which emphasized the importance of dialysis to people with kidney failure. But the messaging has shifted and is now urging people to contact their legislators to oppose the bill. The committee spent $33,000 on advertising with Politico and $26,000 with The Sacramento Bee, among others, according to campaign finance reports.

The coalition and the patients featured in the ads argue the measure will threaten the health care and possibly survival of the California patients who get assistance from the American Kidney Fund, which has said it would cease operations in the state if the bill is adopted.


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

KHN’s ‘What The Health?’: All About Medicare


Can’t see the audio player? Click here to listen on SoundCloud.


Before “Medicare for All,” there was just Medicare, the very popular program that serves 60 million Americans age 65 and older or younger people with certain disabilities.

But while Medicare is much loved by most of those it serves, it is anything but simple.

This week KHN’s “What the Health?” podcast takes a deep dive into Medicare. First, host Julie Rovner talks with Tricia Neuman, a senior vice president in charge of Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Then, panelists Paige Winfield Cunningham of The Washington Post, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner join Rovner for a discussion of some of the Medicare issues on the front burner in Washington in 2019.

Among the takeaways from this week’s podcast:

  • You can’t understand Medicare without getting a handle on its alphabet, from A to D.
  • Medicare also has a robust role for private insurance. About one-third of beneficiaries opt to join private insurance plans that contract with the federal government to provide an alternative to the traditional, fee-for-service government program. And that business is highly profitable for private insurance.
  • As Americans age, many fondly look forward to Medicare, imagining it will pay all their health bills. But the program has hefty cost-sharing requirements and doesn’t cover many expenses, including long-term nursing home care, dental care and most vision care.
  • Federal officials are eager to find ways to cut Medicare’s drug costs. But that raises many questions, such as whether Medicare should negotiate with drugmakers over prices or set up its own formulary of drugs it would cover.
  • An even harder question is how Medicare can work to control costs for the pricey drugs administered in doctors’ offices. Strong congressional lobbying from doctors and drugmakers has derailed efforts to do so in the past.
  • A vexing issue for some seniors is getting observation care at the hospital when they are not sick enough to be admitted but are too sick to go home. Patients receiving observation care likely face bigger cost sharing than if they were admitted and Medicare won’t pay for any nursing home care.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Maryland’s Pilot Program To Offer Dental Coverage To Some Medicaid Recipients Brings Smiles To Desperate Patients

The program is aiming to catch dangerous dental problems before they can result in costly emergency room visits for the Medicaid recipients. Experts were muted in their praise. “It’s a very primitive first step for people who don’t have dental care,” said Dr. Louis DePaola, the associate dean at the University of Maryland’s School of Dentistry. Medicaid news comes out of Minnesota as well.

Sky-High Diabetes Costs Are Forcing Patients To Ration Drugs, Ask For Lower-Cost Prescriptions

Stories of the fatal decision to skip or ration insulin have filled headlines in recent months, but new government data shows just how many people are taking those dangerous measures because of high costs. In other pharmaceutical news: Gilead’s stand-off with the government over Truvada, tips for shopping abroad for cheaper meds, and more.

Shopping Abroad For Cheaper Medication? Here’s What You Need To Know

In its effort to temper the sky-high prices Americans pay for many vital medications, the Trump administration last month unveiled a plan that would legalize the importation of selected prescription drugs from countries where they sell for far less. But the plan addresses imports only at the wholesale level; it is silent about the transactions by millions of Americans who already buy their medications outside the United States.

Americans routinely skirt federal law by crossing into Canada and Mexico or tapping online pharmacies abroad to buy prescription medications at a fraction of the price they would pay at home.

In some cases, they do it out of desperation. It’s the only way they can afford the drugs they need to stay healthy — or alive. And they do it despite warnings from the Food and Drug Administration, echoed by the pharmaceutical industry, about the risk of contaminated or counterfeit products.

“The reality is that literally millions of people get their medications this way each year, and they are either saving a lot of money or they are getting a drug they wouldn’t have been able to get because prices are too high here,” says Gabriel Levitt, president of PharmacyChecker.com, an online company that allows people to compare prescription drug prices among international and U.S. pharmacies.

For people with diabetes, the inability to pay U.S. prices for insulin can be a matter of life and death, which is why so many families look to Canada or Mexico to meet their needs.

Robin Cressman, who was diagnosed with Type 1 diabetes in 2012 and has become a vocal advocate for lower drug prices, says that even with insurance she was paying $7,000 a year out-of-pocket for the two insulin drugs she needs: Lantus and Humalog. At one point, her credit card debt hit $30,000, says Cressman, 34, of Thousand Oaks, Calif.

While on an outing in Tijuana, Mexico, last year, she popped into a few pharmacies to see if they stocked her medications. With little fanfare, she says, she was able to buy both drugs over the counter for less than 10% of what they cost her north of the border.

“I left Tijuana that day absolutely trembling because I could not believe how easy it was for me to get my insulin,” she says, “but also how little money it cost and how badly I was being extorted in the U.S.”

If you are planning to cross the border for your medications, or get them through an online pharmacy abroad, here are two things you should know. First: It is technically illegal. Second: It is unlikely you will be prosecuted.

Despite the official prohibition, FDA guidelines allow federal agents to refrain from enforcement “when the quantity and purpose are clearly for personal use, and the product does not present an unreasonable risk to the user.”

Personal use generally means no more than a 90-day supply. You should think twice before bringing in quantities larger than that, because if authorities suspect you have commercial intentions, you could land in legal jeopardy — and lose the drugs.

People familiar with the practice say you generally can pass through customs without much hassle if you have no more than three months’ worth of a medication, you declare it to customs agents and you show them a doctor’s prescription or a personal note attesting it is for personal use, along with contact information for your physician.

Even in the worst-case scenario, an unsympathetic agent might confiscate the drugs — but not arrest you.

Ordering drugs online from foreign pharmacies also tends to go largely unchallenged. Legally, the FDA can refuse entry of the package at an international mail facility. “That does happen from time to time,” but not often, says Levitt.

It is more common for shipments that do get through to be detained for several days pending FDA inspection. So, if you need to take your medication every day, be sure to build in a sufficient margin for potential delays.

A far bigger risk if you’re shopping abroad for medications is that you might not get what you paid for — and it might not be safe. “There’s a lot of junk in the pharmaceutical world,” says Dr. Ken Croen, a primary care physician at the Scarsdale Medical Group in Westchester County, N.Y., who advises many of his patients on how to buy drugs safely in Canada.

And there are plenty of rogue operators, especially in the world of online pharmacies. You will need to do a little vetting.

Before doing business with an online pharmacy, confirm it is licensed in its country of origin and that the country has strong pharmacy regulations, says Dr. Aaron S. Kesselheim, a professor of medicine at Brigham & Women’s Hospital and Harvard Medical School. (Read below for websites that can help with that.)

Countries with well-regulated pharmacies include Canada, New Zealand, Australia, much of Western Europe and Turkey.

Also, check to make sure the pharmacy posts an address and phone number on its website. Experts advise against using online pharmacies that don’t require a doctor’s prescription: They are more likely to cut other corners, as well.

A couple of websites do the vetting for you, using these and other criteria.

The Canadian International Pharmacy Association runs a site (cipa.com) that allows you to compare drug prices among dozens of pharmacies whose legitimacy it has certified. Its customers “tend to be people who live in the U.S., are on fixed income or low income and can’t afford the medications where they live,” says Tim Smith, the association’s general manager.

To buy through one of CIPA’s certified pharmacies, you must have a valid prescription and submit a medical profile to help guard against adverse drug interactions. The site also maintains a list of “rogue” online pharmacies.

PharmacyChecker.com offers a similar service, linking customers to a broader range of online pharmacies abroad and in the U.S.

Levitt, its president, notes that while importing drugs from overseas is a “critical lifeline” for many people, it is still possible to buy many medications affordably in the U.S. He and others suggest you take the time to comparison shop in the U.S. because prices can vary significantly from pharmacy to pharmacy.

Santa Monica, Calif.-based GoodRx tracks prescription drug prices at over 70,000 pharmacies across the U.S. and offers coupons.

Levitt also recommends asking your doctor if there is a viable therapeutic alternative or a lower-cost generic drug. Recent research from PharmacyChecker shows that 88% of the most commonly prescribed generic drugs can be purchased more cheaply in the U.S. than from Canadian pharmacies.

“Many times there is no reason to go international,” Levitt says. “The drug will actually be cheaper here.”


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

FDA Officials: Stakes Were Too High In Novartis Data Manipulation Case To Do Anything But Publicly Drop The Hammer

The FDA came down hard on Novartis, subjecting the company to a public flogging over the data manipulation that, at the end of the day, didn’t effect patients’ safety. But the issue is too important to give anyone a pass, officials say. “It may sound like we’re kind of bureaucratic paper-pushers, but it’s more than that,” said FDA’s Dr. Peter Marks. “It’s making sure that the whole ecosystem understands that when people are working on these things that are highly technically complex, that they have to work truthfully and accurately.”

Alaska Governor Vetoes Bill To Restore Sharp Medicaid Cuts

Following the move by Gov. Mike Dunleavy and earlier action by the Alaska’s legislature, the state’s Medicaid program is expected to be cut by about 22%. Those state spending cuts mean Alaska will receive at least $127 million less in federal Medicaid matching funds. Medicaid news comes out of Oklahoma and Ohio, as well.

Cigna Explores Sale Of Its Group Benefits Insurance Business In Sign Insurer Intends To Focus On Health Care

Reuters reports that the division Cigna is looking to shed involves disability and life insurance. The move echoes ones made by other insurers looking to focus on health care. In other health industry news: a slew of departures from Apple’s health team, price transparency, hospital chains and purchases, and more.

‘Financially Devastating’ Air Ambulance Rides Can Both Save Lives And Ruin Them

Courts have ruled air ambulances can charge anything they want, and many patients are getting stuck with sky-high bills. Meanwhile, Texas lawmakers signed aggressive legislation into law that was meant to protect the state’s residents from surprise medical bills, but millions remain unprotected.

A Brush With A Notorious Cat, My Rabies Education And The Big Bill That Followed

I was just petting an orange tabby cat in my Falls Church, Va., neighborhood, a cat I’d never met before. He was very cute. And he was purring and butting his head against my hand. Until he wasn’t.

He sunk his teeth into my wrist, hissed at me and ran off. So began my personal episode of Law & Order: Feline Victims Unit, complete with cat mug shots and weekly check-ins from local animal control and public health officials. And rabies shots. Multiple rabies shots in the emergency room. And more than $26,000 in health care costs, an alarming amount considering I was perfectly healthy throughout the whole ordeal.

What I learned, besides fascinating facts about rabies, its transmission and the horrible ways one can die from it, was that any one of us is a mere cat scratch away from financial peril if we aren’t lucky enough to have good health insurance. Our confusing health care system makes it too easy for a person who should get medical care to postpone it or avoid it — even when that decision could be fatal.

After the encounter with the cat, I headed to a nearby storefront urgent care clinic, where a nurse handed me a form to fill out, which the city uses to track animal bites. She faxed the form to the health department and a police officer visited me as soon as I returned home.

I was asked: “Do you know the cat?” After some sleuthing in my neighborhood Facebook group, I developed a suspicion about whom he belongs to. But I couldn’t be 100% positive.

Which is why three days after the bite I was in the waiting room in the emergency room. When an animal bites someone, the procedure is to quarantine it for 10 days. If the animal doesn’t develop rabies symptoms during that time, it’s safe to say the bite victim won’t develop the disease either.

But if the animal can’t be identified or captured, the recommendation is to begin post-exposure preventive treatment for rabies. I’d need a one-time injection of human rabies immune globulin and then four injections of the rabies vaccine over two weeks.

An estimated 40,000 to 50,000 people get such treatments each year following exposure to potentially rabid animals, according to the Centers for Disease Control and Prevention.

I did consider taking my chances and skipping treatment. The odds the cat that bit me was rabid were, I’d guess, almost zero. He was probably someone’s pet and didn’t appear to have any symptoms. But rabies is fatal. That was the line my doctor, the animal control officer, my friends and public health officials kept repeating. A small chance is not the same as no chance.

I tried to be a responsible health care consumer and research cost-effective options. The ER is the only place that can administer immune globulin, so I knew that was my first stop. But I hoped to go elsewhere for the next three appointments, where I would receive the rabies vaccine.

I sat on the phone with insurance company agents while they tried to find an in-network provider that stocked the rabies vaccine. They found nothing. My primary care doctor told me people generally ended up doing the follow-up doses in the ER. The urgent care clinic staff told me they didn’t keep the vaccine in stock but could have ordered it ahead of time if they had known I would need it. Since I hadn’t anticipated being bitten by a cat, I neglected to call ahead.

The staff at the ER told me that specialized clinics for travelers can administer the vaccine, but the procedure is not generally covered by insurance. Also, to adhere to the strict vaccination schedule, I needed a location with Sunday hours, which I was unable to find.

The Fairfax County, Va., public health department said the county does not administer rabies vaccines at its clinics. Two hospital urgent care clinics also told me they couldn’t provide the vaccine, even though one of those clinics is on the same campus as the ER.

Which left me back where I started.

Although my insurance picked up the full tab for that first emergency room visit, the hospital bill came to $17,294.17. My insurance provider negotiated that bill down to $898 and paid it.

For the next three visits, I received doses of RabAvert, made by GlaxoSmithKline. Even though I received the same treatment for each of these visits, the hospital billed my insurance slightly different amounts each time: $2,810.96, $2,692.86 and $2,084.36. (If I could have bought it from a pharmacy, it would have cost about $350 a dose.)

Rabies is not the only possible complication of a cat bite. Many bites become infected, which is why I left my urgent care visit with a 10-day supply of amoxicillin, an antibiotic. According to the police, the cat who bit me is likely a repeat offender. A neighbor recently developed a nasty infection after a bite from a large orange tabby — no one is sure if it is the same cat — and has since needed surgery. She also underwent the rabies treatment.

I was lucky not to develop an infection, but my insurance company did have to pay one final bill — $206 to see my primary doctor after I developed a rash, likely from the antibiotic. If you’re keeping score at home, that brings the grand total to $26,229.35.

I had hoped to donate my blood, now rich with rabies antibodies, to be used to create more immune globulin for future bite victims. Unfortunately, my level of immunity likely isn’t high enough. Most people who give their plasma for this purpose have undergone the rabies vaccine many times. A public health worker said he recommended plasma donation to an acquaintance of his who studies endangered bats — a career I’m unlikely to go into. In fact, if I get bitten by any wildlife in the future, I will still have to trek back to the ER for two more rounds of shots.

So, I leave this experience behind with modestly increased immunity, little understanding of how medical bills are calculated and a new fear of outdoor cats — but also with a new appreciation for public health workers.

As for the cat, the police told me he was put under house arrest.

Most Training Programs For Workers Lacking Skills Show Little Success. This One Was Different.

A program geared toward helping train workers to better position themselves for jobs has found success where others failed. One of the lessons learned, though, is that it takes a lot of investment to do so. In other industry and staffing news, a company that allows health care employers to post job openings for temporary doctors and travel nurses plans to expand.

Courtroom Standoffs: Hospitals On Brink Of Insolvency Trying To Squeeze Money From Patients Who Just Don’t Have It

Emergency room visits can often lead to a court date when the patients can’t pay their bills. In a small Missouri town the practice has become so routine that some people here derisively refer to it as the “follow-up appointment.” In just this town, there can be dozens of cases each week. “I’m trying to make peace with the fact that this debt could sit on me forever,” said Gail Dudley, 31.

ER Redo: As Rural Hospital Closes, Emergency Care Is On The Blink With Fate Uncertain

Linda Findley’s husband, Robert, died after falling on the ice during a winter storm this February in Fort Scott, Kan. Mercy Hospital had recently closed, and Robert had to be flown to a neurology center 90 miles north in Kansas City, Mo., but at least three air ambulance pilots turned down the call from local EMS workers before one accepted.(Christopher Smith for KHN)

FORT SCOTT, Kan. — For more than 30 minutes, Robert Findley lay unconscious in the back of an ambulance next to Mercy Hospital Fort Scott on a frigid February morning with paramedics hand-pumping oxygen into his lungs. A helipad sat just across the icy parking lot from the hospital’s emergency department, which had recently shuttered its doors, like hundreds of rural hospitals nationwide.

Suspecting an intracerebral hemorrhage and knowing the ER was no longer functioning, the paramedics who had arrived at Findley’s home called for air transport before leaving. For definitive treatment, Findley would need to go to a neurology center located 90 miles north in Kansas City, Mo. The ambulance crew stabilized him as they waited.

But the dispatcher for Air Methods, a private air ambulance company, checked with at least four bases before finding a pilot to accept the flight, according to a 911 tape obtained by Kaiser Health News through a Kansas Open Records Act request.

“My Nevada crew is not available and my Parsons crew has declined,” the operator tells Fort Scott’s emergency line about a minute after taking the call. Then she says she will be “reaching out to” another crew.

Nearly seven minutes passed before one was en route.

When Linda Findley sat at her kitchen counter in late May and listened to the 911 tape, she blinked hard: “I didn’t know that they could just refuse. … I don’t know what to say about that.”

Both Mercy and Air Methods declined to comment on Findley’s case.

When Linda first met Robert, he was known for racing cars on the back roads of Fort Scott. They were married 48 years and Robert made a life out of his favorite hobby. He opened Findley Body Repair in 1975.(Christopher Smith for KHN)

When Mercy Hospital Fort Scott closed at the end of 2018, hospital president Reta Baker had been “absolutely terrified” about the possibility of not having emergency care for a community where she had raised her children and grandchildren and served as chair of the local Chamber of Commerce. Now, just a week after the ER’s closure, her fears were being tested.

Nationwide, more than 110 rural hospitals have closed since 2010, and in each instance a community struggles to survive in its own way. In Fort Scott, home to 7,800, the loss of its 132-year-old hospital opened by nuns in the 19th century has wrought profound social, emotional and medical consequences. Kaiser Health News and NPR are following Fort Scott for a year to explore deeper national questions about whether small communities need a traditional hospital at all. If not, what would take its place?

Delays in emergency care present some of the thorniest dilemmas for nurses, physicians and emergency workers. Minutes can make the difference between life and death — and seconds can be crucial when it comes to surviving a heart attack, a stroke, an anaphylactic allergic reaction or a complicated birth.

Though air ambulances can transport patients quickly, the dispatch system is not coordinated in many states and regions across the country. And many air ambulance companies do not participate in insurance networks, which leads to bills of tens of thousands of dollars.

Knowing that emergency care was crucial, the hospital’s owner, St. Louis-based Mercy, agreed to keep Fort Scott’s emergency doors open an extra month past the hospital’s Dec. 31 closure, to give Baker time to find a temporary operator. A last-minute deal was struck with a hospital about 30 miles away, but the ER still needed to be remodeled and the new operator had to meet regulatory requirements. So, it closed for 18 days — a period that proved perilous.

A Risky Experiment

During that time, Fort Scott’s publicly funded ambulances responded to more than 80 calls for service and drove more than 1,300 miles for patients to get care in other communities.

Across America, rural patients spend “statistically significant” more time in an ambulance than urban patients after a hospital closes, said Alison Davis, a professor at the University of Kentucky’s department of agricultural economics. Davis and research associate SuZanne Troske analyzed thousands of ambulance calls and found the average transport time for a rural patient was 14.2 minutes before a hospital closed; afterward, it increased nearly 77% to 25.1 minutes. For patients over 64, the increase was steeper, nearly doubling.

In Fort Scott this February, the hospital’s closure meant people didn’t “know what to expect if we come pick them up,” or where they might end up, said Fort Scott paramedic Chris Rosenblad.

Barbara Woodward, 70, slipped on ice outside a downtown Fort Scott business during the early February storm. The former X-ray technician said she knew something was broken. That meant a “bumpy” and painful 30-mile drive to a nearby town, where she had emergency surgery for a shattered femur, a bone in her thigh.

During the 18 days Fort Scott’s residents lived without an emergency department, Barbara Woodward slipped on ice outside a downtown Fort Scott business. The ambulance that arrived for her had to drive 30 miles out of town. “I thought to myself that the back of the ambulance isn’t as comfortable as I thought it would be,” Woodward says.(Christopher Smith for KHN)

About 60% of calls to the Fort Scott’s ambulances in early February were transported out of town, according to the log, which KHN requested through the Kansas Open Records Act. The calls include a 41-year-old with chest pain who was taken more than 30 miles to Pittsburg, an unconscious 11-year-old driven 20 miles to Nevada, Mo., and a 19-year-old with a seizure and bleeding eyes escorted nearly 30 miles to Girard, Kan.

Those miles can harm a patient’s health when they are experiencing a traumatic event, Davis said. They also prompt other, less obvious, problems for a community. The travel time keeps the crews absent from serving local needs. Plus, those miles cause expensive emergency vehicles to wear out faster.

Mercy donated its ambulances to the joint city and county emergency operations department. Bourbon County Commissioner Lynne Oharah said he’s not sure how they will pay for upkeep and the buying of future vehicles. Mercy had previously owned and maintained the fleet, but now it falls to the taxpayers to support the crew and ambulances. “This was dropped on us,” said LeRoy “Nick” Ruhl, also a county commissioner.

Even local law enforcement feel extra pressure when an ER closes down, said Bourbon County Sheriff Bill Martin. Suspects who overdose or suffer split lips and black eyes after a fight need medical attention before getting locked up — that often forces officers to escort them to another community for emergency treatment.

And Bourbon County, with its 14,600 residents, faces the same dwindling tax base as most of rural America. According to the U.S. Census Bureau, about 3.4% fewer people live in the county compared with nearly a decade ago. Before the hospital closed, Bourbon County paid Mercy $316,000 annually for emergency medical services. In April, commissioners approved an annual $1 million budget item to oversee ambulances and staffing, which the city of Fort Scott agreed to operate.

In order to make up the nearly $700,000 difference in the budget, Oharah said, the county is counting on the ambulances to transport patients to hospitals. The transports are essential because ambulance services get better reimbursement from Medicare and private insurers when they take patients to a hospital as compared with treating patients at home or at an accident scene.

Woodward’s bumpy 30-mile ride was just the beginning of a difficult journey. She had shattered her femur and had trouble healing after emergency surgery. In May, she had a full hip replacement in Kansas City.(Christopher Smith for KHN)

Added Response Times

For time-sensitive emergencies, Fort Scott’s 911 dispatch calls go to Air Methods, one of the largest for-profit air ambulance providers in the U.S. It has a base 20 miles away in Nevada, Mo., and another base in Parsons, Kan., about 60 miles away.

The company’s central communications hub, known as AirCom, in Omaha, Neb., gathers initial details of an incident before contacting the pilot at the nearest base to confirm response, said Megan Smith, a spokeswoman for the company. The entire process happens in less than five minutes, Smith said in an emailed statement.

When asked how quickly the helicopter arrived for Robert Findley, Bourbon County EMS Director Robert Leisure said he was “unsure of the time the crew waited at the pad.” But, he added, “the wait time was very minimal.”

Rural communities nationwide are increasingly dependent on air ambulances as local hospitals close, said Rick Sherlock, president of the Association of Air Medical Services, an industry group that represents the air ambulance industry. AAMS estimates that nearly 85 million Americans rely on the mostly hospital-based and private industry to reach a high-level trauma center within 60 minutes, or what the industry calls the “golden hour.”

In June, when Sherlock testified to Congress about high-priced air ambulance billing, he pointed to Fort Scott as a devastated rural community where air service “helped fill the gap in rural health care.”

But, as Findley’s case shows, the gap is often difficult to fill. After Air Methods’ two bases failed to accept the flight, the AirCom operator called at least two more before finding a ride for the patient.

Robert owned Findley Body Repair and was a much-loved member of the Fort Scott, Kan., community. (Christopher Smith for KHN)

Linda says she doesn’t know what she’s going to do with Findley Body Repair. She kept two workers on for six weeks after Robert’s death to close out active orders. “I guess I’ll have to have an auction someday,” she says. (Christopher Smith for KHN)

The 1978 Airline Deregulation Act states that airline companies cannot be regulated on “rates, routes, or services,” a provision originally meant to ensure that commercial flights could move efficiently between states. Today, in practice, that means air ambulances have no mandated response times, there are no requirements that the closest aircraft will come, and they aren’t legally obligated to say why a flight was declined.

The air ambulance industry has faced years of scrutiny over accidents, including investigations by the National Transportation Safety Board and stricter rules from the Federal Aviation Administration. And Air Methods’ Smith said the company does not publicly report on why flights are turned down because “we don’t want pilots to feel pressured to fly in unsafe conditions.”

Yet a lack of accountability can lead to mostly for-profit providers sometimes putting profits first, Scott Winston, Virginia’s assistant director of emergency medical services, wrote in an email. Air ambulances can be delayed because of bad weather or crew fatigue from previous runs.

Or sometimes companies accept a call knowing their closest aircraft is unavailable, rather than lose the business. “This could result in added response time,” he wrote.

Air ambulances don’t face the detailed reporting requirements imposed on ground ambulances. The National Emergency Medical Services Information System collects only about 50% of air ambulance events because the industry’s private operators voluntarily provide the information.

Months after Robert, died, Linda listened to the 911 call. “I had no idea they could decline,” Findley says of air ambulance crews.(Christopher Smith for KHN)

Saving Lives

It took months, but Baker persuaded Ascension Via Christi’s Pittsburg hospital, which sits 30 miles south of Fort Scott, to reopen the ER. “They kind of were at a point of desperation,” said Randy Cason, president of Pittsburg’s hospital. The two Catholic health systems signed a two-year agreement, leaving Fort Scott relieved but nervous about the long term.

Ascension has said it is looking at potential facilities in the area, but it’s unclear what that means. Fort Scott Economic Development Director Rachel Pruitt said in a July 23 email, “No decisions have been made.” Fort Scott City Manager Dave Martin said the city has entered into a “nondisclosure agreement” with Ascension to look into the health system’s ability to continue offering health care to Fort Scott, though Martin could not confirm whether that included an emergency department.

Nancy Dickey, executive director of the Texas A&M Rural & Community Health Institute, said every community prioritizes emergency services. That’s because the “first hour appears to be vitally important in terms of outcomes,” she said.

And the Fort Scott ER, which reopened under Ascension on Feb. 18, has proved its value. So far, in the past six months, Ascension’s Fort Scott emergency department has taken care of more than 2,500 patients, including delivering three babies. In May, a city ambulance crew had resuscitated a heart attack patient at his home and Ascension’s emergency department staff treated the patient until an air ambulance arrived.

In July, Fort Scott’s Deputy Fire Chief Dave Bruner read a note from that patient’s grateful wife at a city commission meeting: “They gave my husband the chance to fight long enough to get to Freeman ICU. As a nurse, I know the odds of Kevin surviving the ‘widow maker’ were very poor. You all made the difference.”

By contrast, Linda Findley believes the local paramedics did everything possible to save her husband but wonders how the lack of an ER and the air ambulance delays might have changed her husband’s outcome. After being flown to Kansas City, Robert Findley died.

This is the third installment in KHN’s year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium.

Sky-High Surprise Bills From Air Ambulance Rides Under Scrutiny In Georgia

More insured patients are being hit by surprise medical bills, with air ambulance charges among the worst. The prices can be in the tens of thousands of dollars and more than half of rides in the U.S. on air ambulances are not in the passenger’s insurance network. Georgia legislators say they want to do something about that. The state is also looking to overhaul other aspects of its EMS services. And in Virginia, regulators will seek public input from residents about actions the state could take to limit surprise bills.