Tagged Health Industry

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Nursing Homes Have Thousands Of Ventilators That Hospitals Desperately Need

As the number of COVID-19 patients climbs and health officials hunt for ventilators to treat them, nursing homes across the United States have a cache ― about 8,200 of the lifesaving machines, according to data from the Centers for Medicare & Medicaid Services.

Most of the machines are in use, often by people who’ve suffered a brain injury or stroke. Some of those residents are in a vegetative state and have remained on a ventilator for years.

State officials are working to consolidate ventilators where they are most urgently needed. But so far, the supply in nursing homes has not drawn the same attention.

Or course, commandeering those units would set up a monumental ethical dilemma: Do you remove life support for a long-term nursing care patient in order to give a COVID-19 patient a better chance of survival?

The highest number of machines, about 2,300, is in California, where the state has created designated nursing home units for people on life support, officially called subacute units but known pejoratively by some doctors as “vent farms.” New York has the second most, 1,822, according to state officials.

Already, one nursing home on Long Island has lent a nearby hospital 11 ventilators that were not being used, leaving just five for its residents.

“The hospital came to us last week and asked, ‘Do you have any ventilators?’” the nursing home assistant administrator said on the condition of anonymity because he was not authorized to speak to the news media.

“We left ourselves with the bare minimum,” he said. In all, three hospitals reached out to the nursing home for ventilators ― it had to say no to the other two.

New York Gov. Andrew Cuomo has announced an executive order that ventilators not in use by hospitals be redeployed to ICUs. And he’s calling in the New York National Guard to facilitate the order. “We know where every ventilator is,” Cuomo said Sunday.

Nursing home ventilators are not included in his order, but they are included in the state’s tally of the machines.

Dr. Michael Kalafer, a pulmonologist and the medical director at two San Diego subacute units, said he can’t imagine taking one of his patients off a ventilator because it’s needed for someone else.

“I severely doubt we’ll take [a hypothetical] Mrs. Smith off a ventilator because she’s 80 and has been on it for a few years and has not gotten better,” Kalafer said.

But these are precisely the decisions bioethicists are being asked to weigh in on as the country confronts the crush of COVID-19 patients overwhelming the health care system.

And in some cases, states have already decided to give people who are severely brain-injured a lower priority when it comes to access to ventilators. Disability advocates oppose such guidelines and filed complaints with the Department of Health and Human Services last month, according to ProPublica. And although states and health associations can draw up recommendations, they are not legally binding.

“From an ethical point of view, for people who are not conscious, if it’s a matter of removing people from a [ventilator] who are not going to recover, I think it’s a hard decision, but one that in an emergency has to be made,” said Ronald Bayer, a professor of sociomedical sciences at the Mailman School of Public Health at Columbia University.

Bayer has been a member of the World Health Organization and in 2011 served on an ethics subcommittee that advised the Centers for Disease Control and Prevention on the allocation of ventilators in the event of a severe pandemic.

He and several other ethicists said these decisions should not be made at the bedside but by triage committees or people in supervisory roles. And the guidelines ought to be uniform and transparent. That’s why the CDC, the state of New York and medical associations like the American College of Chest Physicians have drafted ethical recommendations for deciding how to ration lifesaving equipment like ventilators in the event of a pandemic.

The California Department of Public Health in 2008 released guidelines to follow during a health care surge: They don’t specifically address ventilator allocation, but rather resources in general. Doctors should consider the likelihood of survival and change in the quality of life as opposed to the ability to pay or the perception of a person’s worth when there are not enough medical resources to treat everyone in need.

When the New York State Task Force on Life and the Law updated its ventilator allocation guidelines in 2015, it considered the question of withdrawing ventilators from nursing home residents, or chronic ventilator patients, to save the lives of those who grow critically ill during a pandemic.

“Are we comfortable sacrificing this group in exchange for saving more lives?” asked Stuart Sherman, the executive director of the task force at the time.

That question drew much debate, but the group ultimately decided that “chronic” vent patients should not be included in the pool when considering how to allocate ventilators during a pandemic. The task force does recommend prioritizing ventilator therapy based on who is likely to survive using a SOFA ― Sequential Organ Failure Assessment ― score.

Cuomo, whose daily televised news conferences have made “ventilators” a household word, is not making decisions based on those guidelines. The task force report is not a binding policy document, according to a spokesperson from the governor’s office.

In the U.S., there are about 62,000 “full-featured ventilators,” the kind needed to treat the most severe cases of COVID-19. An additional 10,000 to 20,000 ventilators are in the government’s National Strategic Stockpile, and 98,000 basic models, the kind often in nursing homes, exist that could be used in a crisis.

In the simplest terms, ventilators push oxygen into the lungs. The machines in ICUs are more powerful and have better monitoring systems than those in a nursing home.

Kalafer’s patients need ventilators to do the work for respiratory muscles. He said they could be used in a pinch during the pandemic. But the real issue is finding enough staff trained to operate and monitor the machines.

Meanwhile, a group of bioethicists, physicians and public health experts are recommending that in a shortage, health care workers could disconnect people from ventilators who have little or no chance of recovery to put them in service of those who do.

The recommendation is the first of six listed in an article published in the New England Journal of Medicine last month.

It did not consider the people who’ve been on vents long term.

“Honestly, before you emailed me, I thought about those patients but never thought about the actual number and how important that might be,” said Dr. James Phillips, one of the paper’s authors and chief of disaster and operational medicine at George Washington University Hospital.

“For patients who have devastating neurological injury and are deemed to never recover and who require ventilation for the rest of their lives, I think it’s an ethical conversation to have with those families to determine if it’s a more appropriate use of resources,” Phillips said.

One ventilator can save multiple lives. The average time a person sick with COVID-19 who needed a ventilator was 11 days, according to an NEJM article that looked at critically ill patients in the Seattle region. Using that number, eight people could potentially be saved over three months.

It is an especially complex moral dilemma when considering the withdrawal of treatment from someone who has lived several years on a ventilator, said Govind Persad, an assistant professor at the University of Denver Sturm College of Law and one of the authors of the NEJM paper.

Persad offered a hypothetical scenario.

“A 78-year-old grandmother has been on ventilator support for 5 years in a subacute facility and is expected to remain on it for the foreseeable future. Covid-19 has reached a senior apartment complex nearby, and doctors are looking everywhere for more ventilators,” Persad wrote.

“They think one more ventilator would give them a chance of saving another 78-year-old grandmother in the senior apartments who is growing worse with viral pneumonia, and, once she is off the ventilator, to save some of her neighbors, who are not yet sick but who they expect to be sick in a few weeks.”

Who gets the ventilator?

Persad suggested it should go to the grandmother in the senior apartments because she is likely to need less time on the ventilator, enabling the ventilator to be used to save her neighbors later.

As he put it: “We save her in order to save more lives, not because of quality-of-life judgments.”

The real-life decision is more problematic and heart-wrenching.

Nancy Curcio’s daughter Maria, who was born with a disabling form of cerebral palsy, was on a ventilator as an adult in San Diego for about three months in 2004. She was eventually weaned off the machine but lived the remainder of her life in a nursing home with a breathing and feeding tube, unable to walk or talk. She died in 2017 at age 57.

“I would be very upset if a doctor said I have to take her ventilator away for someone to live,” Curcio said. “But I can understand in triage this is what a doctor has to do. Would I like it? No. I would want to run away with the ventilator.”

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Dispatch From A Country Doctor: Seeing Patients Differently In The Time Of Coronavirus

Patients would often stop by River Bend Family Medicine just to gab with staff at the front desk or bring baked goods to Dr. Matt Hahn.

“I’m a simple country doctor,” said Hahn, who has practiced in Hancock, Maryland, for 20 years ― the past decade at his River Bend office. “Our waiting room is like a social network in and of itself.” Hahn is also a candidate for West Virginia’s 2nd Congressional District though he has backed away from campaigning because of the coronavirus threat.

His waiting room is now closed for the same reason. But Hahn’s practice in this small town — pinned hard up against the borders with West Virginia and Pennsylvania, about 100 miles northwest of Washington, D.C. ― is not.

Patients who need an in-office appointment call when they get to the parking lot and wait there instead. A staff member escorts them in, opening all the doors, telling patients not to touch anything. Those who are ill use one specific entrance, which leads them upstairs where they are met by staff who follow strict infection-control measures. The rest, such as those coming in with a wound or a diabetes checkup, are treated downstairs.

Still, Hahn now sees most of his patients in telehealth appointments, linked to their computers or smartphones. He can do a lot over video and phone, he said. Some things present more of a challenge, though. With rashes, for example, “people are angling their bodies to show a body part to their camera,” said Hahn. “We’ve had some fun with that.”

Humor remains important during this coronavirus crisis. But, jokes aside, Hahn isn’t taking any of it lightly. As of April 6, 37 coronavirus cases were confirmed in Washington County, which encompasses Hancock, and the governor of Maryland on March 30 issued a statewide stay-at-home order.

On March 17, the Trump administration used emergency powers to expand Medicare payments for telemedicine so that more doctors, hospitals and clinics could be paid for such services. While the expansion applies only to Medicare, Hahn said other insurers moved quickly to do the same. Previously, telemedicine coverage was generally limited to people in remote or underserved areas. Even though it’s at least 30 minutes from the nearest hospital, Hancock is not considered remote.

“It’s something we really wanted to do — we didn’t want to shut our doors,” said Hahn, who trained at George Washington University School of Medicine, in Washington, D.C.

Across the country, practices large and small, like River Bend, are enlisting the help of such technological innovations. In addition to the changes to Medicare reimbursement rules, the administration has loosened privacy enforcement for medical providers making “good faith” efforts to use non-public video services: Facebook Messenger is OK, for example, but Facebook Live is not.

Still, online visits are not perfect.

For one thing, internet service can be spotty, Hahn and nurse practitioner Lora Cole said. Another concern: The new rules required the use of both audio and video in consults with patients. But on March 30, the Centers for Medicare & Medicaid Services took an additional step of further loosening telehealth restrictions to allow providers to conduct the telehealth exams for beneficiaries who have audio phones only.

Another concern is that some patients are not that familiar with computers or smartphones, making telehealth consults more challenging, according to Hahn. And a number of them don’t have access to the internet.

For those who do, the staff tries to help them download apps, go to websites, adjust their cameras or turn on the audio.

“The first few days were frustrating. We spent much of the day trying to get people to paste an address into the right line and put in a nine-digit code,” said Hahn.

Part of the problem was they were trying to use a wide variety of different websites or apps. Once they narrowed the choices, the process got easier. Hahn settled on using Google Duo on his phone, while Cole and the other nurses use the web service GoToMeeting in their virtual exam room.

“We give them the code. They click join. It’s a couple of steps that are very quick and easy,” said Cole.

Those who struggle aren’t having problems with the programs themselves, she said, but with maneuvering their smartphone or computer. She and the nurses in the office walk them through it when they can.

“We take a big deep breath,” said Cole. “With some of our patients, we have actually asked them to find someone ― a family member — who can help them.”

The visits themselves work out just fine, even if they are missing a certain, well, human element, both say.

“It has been very hard on my heart,” said Cole, who said her patients know she loves elephants, often bring her presents to add to her collection of pictures, figurines and other tchotchkes. “I miss my patients. I miss being able to see them and give them a hug.”

Clinically, it has limitations, as well.

“I can’t see the entire body. I can’t do a physical exam,” said Hahn. “But, this is a wonderful thing to have right now. Until we have some break in this situation, we want to keep people home. This gives us the opportunity to take care of patients and keep patients safe and staff safe. Under these circumstances, I am not complaining.”

Someday, Hahn and Cole hope things return to normal, whenever that will be.

And what will things look like at River Bend when it’s all over? Will they still rely heavily on video visits? It hasn’t come up yet.

“We just don’t have time to think or even discuss what the future may hold,” said Cole. “We’re just totally focused on what we have to do that day. Personally, I want it to go back. I want to see my patients again.”

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Second Time Around? Health Care Issues Trump Might Tackle If Reelected

If President Donald Trump wins a second term in the White House, what health care policies might the nation expect from his administration?

Julie Rovner, Kaiser Health News’ chief Washington correspondent, examines that issue in the new edition of Washington Monthly magazine.

Although changes in health care might not have ranked high on the president’s priorities for a second term ― particularly if Democrats retain a majority in the House of Representatives — external factors such as the coronavirus pandemic could force the White House and Congress to work together to improve the nation’s public health infrastructure. And the administration might move to weaken the Affordable Care Act through regulations. You can read the article here.

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‘You Pray That You Got The Drug.’ Ailing Couple Gambles On Trial For COVID-19 Cure

Josie and George Taylor stand on the porch of their home in Everett, Washington, on March 24. They are two of the first people in the U.S. to recover from novel coronavirus infections after joining a clinical trial for the antiviral drug remdesivir.(Dan DeLong for KHN)

For 10 days last month, they lay in side-by-side isolation units in a Seattle-area hospital, tethered to oxygen and struggling to breathe as the coronavirus ravaged their lungs.

After nearly 52 years of marriage, that was the hardest thing: being apart in this moment, too weak to care for each other, each alone with their anxiety and anguish.

“I worried about my husband a lot,” recalled Josie Taylor, 74, who fell ill a few days before George, 76. “Yes, I was concerned about me, but I was more concerned about what was going to happen to him.”

Despite their personal uncertainty, when a doctor approached the Taylors at their bedsides to ask if they would consent to join a study of an experimental drug to help experts learn to treat the devastating infection, each agreed.

“My answer was absolutely yes,” Josie said. “My feeling was anything I can do to help. Even if you’re stuck in an isolation room, this is affecting so many people and we have to do everything we can.”

In late March, the Taylors were discharged from EvergreenHealth medical center, heading home a few days apart. They returned to their tidy white house in Everett, tired, worn — and wondering if the clinical trial they had joined is the reason they survived the deadly disease.

The couple are among the first patients in the U.S. to recover from COVID-19 after agreeing to participate in a National Institutes of Health randomized controlled trial of remdesivir, an antiviral drug made by Gilead Sciences that once aimed to treat another infectious disease, Ebola.

The study is part of a surge in efforts to beat back the virus that as of Sunday evening had sickened more than 337,000 people in the U.S. and led to more than 9,600 known deaths.

“You pray that you got the drug,” said Josie. “The fact that we both recovered so quickly? You hope that’s the reason why.”

But neither the Taylors nor Dr. Diego Lopez de Castilla, the 41-year-old physician heading the trial at the Kirkland, Washington, hospital, know now whether the couple received injections of remdesivir — or an identical-looking placebo.

Nor do they know whether the investigational drug, designed to stop the virus from replicating, is effective at halting the disease. There are a half-dozen studies in progress across the globe testing remdesivir as a COVID-19 treatment.

At the same time, more than two dozen Phase 3 clinical trials are recruiting participants to study interventions to prevent or treat COVID-19. They range from a tuberculosis vaccine being tested on health care workers to a cancer drug that could prevent the deadly fluid buildup occurring in the lungs of COVID-19 patients.

Other drugs, including those used to treat rheumatoid arthritis and even gout are being tested to see if they reduce the body’s inflammatory response to the infection. A few studies aim to confirm whether treatments touted by President Donald Trump, the antimalarial drugs chloroquine and hydroxychloroquine, are indeed effective against COVID-19.

If any of the trials show overwhelming evidence of benefit or harm, they could be called off, with the drug in question accelerated to general use or halted.

So far, no drug appears to be a certain treatment for COVID-19. Early results regarding remdesivir are expected in late April. Officials with the World Health Organization and many media accounts have suggested the treatment could hold promise. But it’s too soon to say, said Lopez de Castilla.

“I don’t think we have enough data to be commenting,” Lopez de Castilla said. “I think it’s very premature. We’re still enrolling patients in the trial.”

Lopez de Castilla is steering clear of the political turmoil that has surrounded remdesivir and Gilead. The firm in March sought and received federal Food and Drug Administration approval for so-called orphan drug designation, but then asked the agency to rescind the designation after critics accused company officials of unfairly seeking a lucrative monopoly for the drug.

Orphan drug designation gives a manufacturer seven years of market exclusivity, a period that essentially bars competition. Consumer advocates criticized the designation because orphan drug status is aimed at products that target rare diseases, those that affect 200,000 people or fewer. Gilead received the status when U.S. cases were still hovering near 40,000 but were expected to rise far higher.

In the past two weeks, Gilead officials announced that, because of “overwhelming demand,” the company would no longer provide the drug on an individual compassionate-use basis to patients not enrolled in clinical trials and was shifting to a broader-access program.

For now, Lopez de Castilla is focused on the science, working to follow strict protocols set by the National Institute of Allergy and Infectious Diseases study expected to enroll 440 patients across 75 sites.

The double-blind trial calls for participants to receive the active drug or placebo for 10 days, and then to evaluate how they do based on a scale that moves from fully recovered to death. The drugs are given free to hospitals and trial patients. In a public letter March 28, Gilead chief executive Daniel O’Day pledged that the company would work to “ensure affordability and access.”

Since Feb. 21, 40 U.S. sites have joined the Adaptive COVID-19 Treatment Trial, with Lopez de Castilla’s team enrolling among the most patients so far: at least 20 as of April 1.

“We are a community hospital,” he said. “Although we don’t have all the resources that bigger hospitals have, we do have amazing people here.”

Still, it hasn’t been easy. For weeks, EvergreenHealth was at the epicenter of the U.S. outbreak, treating dozens of patients from the Life Care Center nursing home in Kirkland, where nearly 40 patients have died. Overall, the hospital has treated nearly 300 COVID-19 patients since Feb. 28.

The patients enrolled in the trial are among the sickest, Lopez de Castilla said. They’re those who are moderately to critically ill, including some who are unconscious and on ventilators. Obtaining consent to participate in a clinical trial from patients or families grappling with an emergency has been “very challenging,” he said.

“One of the challenges is how to enroll a patient who is already intubated,” he said. “We do this through a family member, someone who can make medical decisions for the patient.”

It can take hours to explain the procedure, describe the side effects — which could include gastrointestinal problems or elevated liver enzymes — and provide detailed information so the patient or their legal representative can make an informed decision.

Patients must understand that they could receive an unproven therapy, he said. And they need to know that, because the trial calls for half of the patients to receive the drug and half to receive a placebo, there’s a 50% chance they won’t actually receive the active drug.

One barrier has been that the trial paperwork is available only in English, which is not the first language of some patients. EvergreenHealth is working with the NIH to create at least one translation in Spanish.

Overall, about half of the patients Lopez de Castilla approached have said no.

The Taylors both fell ill in early March and ended up in a Seattle-area hospital with COVID-19, before deciding to join a clinical trial for an experimental drug. For Josie Taylor, a former second-grade teacher who volunteers for social causes, the decision was easy. “It does have to be studied,” she says. “It can’t be a knee-jerk reaction of ‘Take any medication, without knowing what the results will be.’”(Dan DeLong for KHN)

For Josie Taylor, a former second-grade teacher who volunteers for social causes, the decision to join the trial was easy. “It does have to be studied,” she said. “It can’t be a knee-jerk reaction of ‘Take any medication, without knowing what the results will be.’”

She and her husband, a retired banker, fell ill in early March, just weeks after moving from their home of 40 years to a new community 30 miles north of Seattle. Josie got sick first.

“I went to the grocery store and came out, loaded the stuff in the car and realized I was very short of breath — weirdly so,” she recalled.

She ran a fever that night, called her doctor and went to the emergency room the next morning, where she was quickly placed in isolation.

George Taylor is a Vietnam War veteran who was affected by the defoliant Agent Orange used in that war. He has multiple health problems, including prostate cancer, heart disease and Parkinson’s disease. Within a couple of days, he also fell ill.

George was sent to the ER and then to an isolation room — next to his wife’s. For more than a week, they were both seriously ill, on oxygen, uncertain about the future. “It was 10 or 11 days,” Josie said, adding wryly: “Honestly, you lose track when you’re having fun.”

Contracting the novel coronavirus has been scary. But they were heartened by the support of family, friends, even people they barely knew. “I came home to a brand-new place with brand-new neighbors and our yard had been mowed and edged,” Josie said.

Now that they’re both home, the Taylors are gradually getting back to normal. Josie still speaks slowly, pausing to catch her breath between words. She said she hopes her experience underscores the seriousness of the crisis.

“I’m hoping and praying that this drug helps a lot of people,” she said. “It’s not an old person’s issue. It’s an every person’s issue.”

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‘You’ve Been Served’: Wisconsin Hospitals Sued Patients Even During Pandemic

When her doorbell rang Sunday night, Blanche Jordan was just starting a new Game of Thrones puzzle on her living room floor.

Jordan, 39, is a breast-cancer survivor who is taking social distancing seriously, so she put on a mask before opening the door. A woman handed Jordan a paper and said: “You’ve been served.”

The paper was a court summons that said Froedtert Memorial Lutheran Hospital, Inc. was suing Jordan for $7,150. Just three weeks before, Jordan had paid off a different $5,000-plus Froedtert debt linked to a hysterectomy that her insurance did not cover.

A lawsuit was the last thing Jordan expected during a viral pandemic.

“This lady came to my door. She didn’t have a mask on. She didn’t have gloves. And she looked at me like I’m crazy because I had a mask across my face,” said Jordan, who lives in Milwaukee and works as a caregiver at an assisted living facility outside of the city. “I’m high-risk,” she said.

Life in Wisconsin, as in the rest of the country, has been transformed by COVID-19 in the past three weeks. Wisconsin declared a public health emergency on March 12, yet firms representing health systems in the state continued to sue patients over medical debt.

Jordan is one of at least 46 people sued by Froedtert in small claims court since March 12. Those cases are among at least 104 similar suits filed statewide by health systems over the same period, according to an analysis of small claims cases by Wisconsin Public Radio and Wisconsin Watch.

Steve Schooff, a spokesman for the hospital, said Tuesday that Froedtert “suspended filing small claims suits” as of March 18 in response to COVID-19.

“In addition, we continue to work with patients related to financial counseling and are allowing patients with financial hardship who are on a payment plan to defer payments while financial assistance is discussed with them,” he said.

Yet court records at the time showed at least 18 lawsuits filed on the hospital’s behalf since then, including 15 filed on March 31 alone. (The suit against Jordan was filed on March 17; she was served on March 29.) Schooff did not explain the discrepancy. All 18 of those cases have since been dismissed.

‘Really? In The Middle Of All This?’

Court records show that at least six additional health systems have also sued patients during the pandemic.

UW Health in Madison has filed 19 lawsuits since March 12. Marshfield Clinic, which covers northern, central and western Wisconsin, has filed at least 14 since that date, followed by Bellin Health, based in Green Bay (11); La Crosse-based Gundersen Health System (10); and Aspirus Grand View Health System, which serves parts of northern Wisconsin (3). Froedtert South, which serves southeastern Wisconsin, also filed one suit.

Bellin chief operating officer and chief financial officer Jim Dietsche said Thursday the health system ceased legal actions on debt collection on March 18, and that the nine suits filed since then were “an error and we apologize for that.”

The five other systems contacted for this story said they have since paused certain legal actions, which court records support.

Tom Russell, a UW Health spokesman, said the health system instructed its legal agencies on March 26 “to cease pursuit of any legal activity.”

“These should be stopped for now,” he said.

Tom Duncan, vice president and chief operating officer for Froedtert South, said his system has generally “suspended filing small claim suits” during the pandemic. “However, in rare circumstances, certain small claim suits may be filed to preserve Froedtert South rights. For example: If a medical debt has been in existence for six years, and the statute of limitations is about to end.”

One Madison resident described being “mortified” when a process server knocked on her family’s door on March 28 to serve papers for a UW Health lawsuit over $1,135.90 in medical debt. UW Health filed that lawsuit before March 26. In a phone interview, the resident asked not to be named in this story because she was embarrassed by the debt related to her husband’s heart condition.

“I couldn’t believe someone would do that,” she said about receiving legal papers during a pandemic. “They’re our bills, but really? In the middle of all of this?”

The woman said her husband offered the process server sympathy, apologizing that the man had to serve papers during a public health emergency.

The woman, who works for a Madison-based nonprofit, saw things differently. “That’s a choice, too. I wouldn’t be able to sleep at night.”

Medical Debts And State Response

Some hospitals have stopped the practice of suing patients in recent months following investigative reporting by Kaiser Health News, MLK50, ProPublica and other outlets.

Jessica Roulette, an attorney with Legal Action of Wisconsin, which provides free legal services to low-income people, said medical bills often fall below things like rent, utilities and food in the “hierarchy of bills and obligations.” Most people facing hospital lawsuits are working and “underinsured,” with plans that leave them on the hook for thousands of dollars in health bills, Roulette said.

Bobby Peterson, executive director of ABC for Health, a nonprofit public-interest law firm in Madison, called it stressful under normal circumstances to face a medical debt lawsuit.

“Today it’s a whole new ballgame,” he said, referring to workers who have lost their jobs and possibly health insurance during the pandemic.

Peterson saw a possible disconnect between some hospitals’ recent decisions to stop suing and the law firms they’ve retained.

“Are the hospitals communicating their own policies internally? And are they communicating with their hired guns out there, making sure that they back off?” Peterson asked.

Paycheck To Paycheck

The state of Wisconsin considers Blanche Jordan, the Milwaukee caregiver, an “essential” worker during the pandemic, meaning her job is not subject to the “Safer At Home” order. She works five days each week at an assisted living facility from 7 a.m. to 3 p.m., alternating work on the weekends. The pay — $15.75 per hour — barely covers her expenses.

Rent, health insurance, utilities and the nearly $300 in garnishments by Froedtert that recently ended, left Jordan with little of her $1,300 biweekly paycheck to spend on other necessities. She filed for bankruptcy in 2016 when, despite being insured, she said she could no longer afford to pay off her debts from treating her aggressive breast cancer.

That journey briefly left her homeless following an eviction, but she generally manages to pay her current landlord on time, Jordan said.

“I’m blessed to have a landlord that’s understanding because his wife died of breast cancer,” she said.

Jordan said her most recent medical debt stemmed from a hysterectomy that was separate from but related to her cancer treatment. She chose Froedtert to perform the procedure, considering it “the best hospital that we have in Wisconsin.”

What she did not realize, she said: Froedtert did not accept her insurance, which she purchased on a federal exchange created by the Affordable Care Act. Hospital administrators accepted and ran her insurance card, Jordan said, but never mentioned that her insurer would not cover the procedure.

In 2019, a judge in the Milwaukee County Small Claims Commissioner Court awarded Froedtert a judgment against Jordan for about $5,300, including court fees, which the hospital claimed by garnishment of her wages. She finished paying that debt during the first week of March — only to be served papers for the alleged $7,150 debt three weeks later.

Jordan assumes this covers the remainder of the bill for her hysterectomy, which she remembers totaling around $12,000. Wisconsin caps small claims at $10,000.

She will eventually see her day in court, although it’s not clear when. The coronavirus postponed her court date to May 28, assuming court proceedings resume by then.

Until then, Jordan will continue to take care of people at the assisted living facility, and she will otherwise stay isolated at home, she said, likely playing Scrabble or Uno with her family.

This story is part of a partnership that includes Wisconsin WatchWisconsin Public RadioNPR and Kaiser Health News.

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Trump Administration Uses Wartime Powers To Be First In Line On Medical Supplies

The Trump administration quietly invoked the Defense Production Act to force medical suppliers in Texas and Colorado to sell to it first — ahead of states, hospitals or foreign countries.

It took this action more than a week before it announced Thursday that it would use the little-known aspect of the law to force 3M to fill its contract to the U.S. first. Firms face fines or jail time if they don’t comply.

The Cold War-era law gives federal officials the power to edge out the competition and force contractors to provide supplies to them before filling orders for other customers.

While it’s unclear how many times the power has been used during the coronavirus pandemic, federal contracting records examined by Kaiser Health News show that federal authorities staked first rights to $137 million in medical supplies. The orders in late March flew under the radar, even as dog-eat-dog bidding wars raged among states and nations for desperately needed medical protective gear.

“It’s like ‘Lord of the Flies’ out there for states and hospitals as they bid against each other for critical medical supplies and equipment,” Sen. Chris Murphy (D-Conn.) said in a statement to KHN. “Plus, there’s no transparency about what the federal government is doing with the equipment that they purchase when they outbid states and hospitals.”

Without public awareness of what was taken on a federal-first basis — and who it was given to — the states are left in the dark after being told repeatedly to procure their own goods. The federal government, President Donald Trump has said, is not the states’ “shipping clerk.”

“It’s putting people into the free market where the invisible hand doesn’t care who it strangles,” said Arthur Caplan, director of the division of medical ethics at New York University School of Medicine.

Trump enacted the first-in-line power of the DPA for the Health and Human Services Department in an executive order on March 18 — and nine days later extended the power to the Department of Homeland Security, which includes the Federal Emergency Management Agency.

On Thursday at his White House press briefing, Trump announced he had invoked the DPA “against” 3M. His executive order states that the government “shall use any and all authority available under the Act to acquire … the number of N-95 respirators that the Administrator determines to be appropriate.”

“We hit 3M hard today after seeing what they were doing with their Masks. ‘P Act’ all the way,” the president tweeted. “Big surprise to many in government as to what they were doing – will have a big price to pay!”

While the administration had asked the company to stop exporting respirators to the Latin American and Canadian markets, 3M stated in a press release Friday there would be humanitarian implications, since the company supplies a critical amount of those countries’ N95 masks. 3M also warned such a move could create a potential trade war where other countries then refuse to sell N95s to the U.S., potentially resulting in fewer N95s in the United States.

When federal authorities use the DPA to seek a so-called rated order, it relieves companies from having to decide which state or hospital or foreign government gets the goods first, said Eric Crusius, a partner at the Washington, D.C., firm Holland & Knight and a contract law specialist. It makes things simple — the federal government’s order is filled first.

The defense law was cited in contracts for an estimated $54 million in medical supplies from Colorado-based Marathon Medical Corp., a medical supply distributor, and an estimated $84 million from Texas-based Retractable Technologies Inc., which makes retractable needles.

A woman who answered the phone at Marathon Medical declined to give her name and said the company policy is not to talk to the media. Officials for RTI, contacted by phone and email, did not respond by press time.

Contracts show that federal HHS officials also invoked their right to be first in line for an estimated $13.5 million in goods produced by New Jersey-based health care products manufacturer and supplier Becton, Dickinson and Co.

A modification to that contract signed March 23 says it applies to “medical and surgical instruments, equipment and supplies” and cites “delegation of authority” under the Defense Production Act “ordered by President Donald J. Trump in response to” the threat of the coronavirus. It’s not clear what product officials ordered from the company.

Becton, Dickinson and Co. told KHN on Thursday that the contract had been modified — again — so that the Defense Production Act was not invoked. Because there is a lag in federal contract disclosures, it’s possible that the contracts for Retractable Technologies and Marathon Medical also have been modified.

All three records name the contract-awarding agency as the HHS Office of the Assistant Secretary for Preparedness and Response and note: “Only the agency awarding the contract may place orders.”

When federal officials made a similar move in Massachusetts, it took state leaders by surprise. Marylou Sudders, who leads the state coronavirus command center, said an order of 400 masks from MSC Industrial Supply was canceled abruptly due to federal intervention, according to a report in The Boston Globe.

MSC spokesperson Paul Mason told KHN that the Defense Production Act compelled his company to put federal orders first.

That cancellation and a similar seizure of goods sowed so much distrust in Massachusetts that the New England Patriots sent a team plane to ship personal protective gear from China, according to The Boston Globe.

Officials from the White House and FEMA declined to directly answer questions about the use of the 1950 law to put the feds first in line for goods. HHS provided a statement saying the Defense Production Act is “an important tool that may be used when necessary to ensure needed supplies are available and going where they are most urgently needed. HHS and FEMA are and will continue working with the private sector and States to increase supply and allocate needed PPE.”

Top Democratic leaders and even a Republican governor were clamoring for a change in how the market was run in recent weeks, as health care workers warned against being sent out to the coronavirus front lines without proper supplies.

In a letter to the president Thursday, Senate Minority Leader Chuck Schumer called for strong federal intervention and leadership on the issue, citing the need for a military logistician to run such a response.

“While you continue to dismiss the Defense Production Act as not being needed, it is clear that the capacity of American industry has not yet been fully harnessed,” Schumer’s letter says.

Trump fired back with his own letter that evening, stating that Navy Rear Adm. John Polowczyk, currently serving as the leader of FEMA’s supply chain task force, was in charge of “purchasing, distributing, etc.”

“The Defense Production Act (DPA) has been consistently used by my team and me for the purchase of billions of dollars’ worth of equipment, medical supplies, ventilators, and other related items,” he wrote. “It has been powerful leverage, so powerful that companies generally do whatever we are asking, without even a formal notice.”

But if the government is going to take more control — which many health and government leaders have urged it to do — it should be transparent about its actions, said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. He said medical leaders have been whiplashed by their orders for protective gear falling through and speculated that they lost out to federal agencies.

Some institutions “fully expected to be able to purchase [personal protective equipment] from contractors who then turned around and said, ‘No, we’re going with another buyer instead,’” he said.

When asked about this phenomenon during Thursday’s national briefing, Trump said the governments could work it out.

“If you think there is bidding between federal government and state, let us know and we’ll drop out immediately,” Trump said. “There are 151 countries that have this problem, and they’re ordering, too. It’s really a mess.”

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As The Country Disinfects, Diabetes Patients Can’t Find Rubbing Alcohol

While the masses hunt for toilet paper, Caroline Gregory and other people with diabetes are on a different mission: scouring stores for the rubbing alcohol or alcohol swabs needed to manage their disease.

Gregory stopped in Carlie C’s, Dollar General and then Harris Teeter in Fayetteville, North Carolina, in pursuit of this vital component of her medical routine.

“We’re all supposed to be staying at home, and I’m out going to 10 different stores,” said Gregory, 33, whose diabetes could heighten her risk for COVID-19 complications. “That’s also not safe.”

Rubbing alcohol and alcohol swabs or wipes are the latest products swept up by the nation’s demand for anything and everything seen as a disinfectant against the novel coronavirus — by hospitals and average consumers alike.

Andy Lerman, vice president of operations for Hydrox Laboratories, a manufacturer based outside Chicago, said the majority of the low-profit-margin medical product his company makes is headed to hospitals, which are going through it faster than they have in the past. He has seen distributors order more than five times the amount they typically do.

“Hospitals are wiping down everything all the time — with every type of virucide that they have at their disposal,” he said. “I’m making it as fast as I can, but I have more orders than I have capacity to manufacture.”

Isopropyl alcohol — a primary ingredient in some types of rubbing alcohol — has been touted as a cleaner that neutralizes the coronavirus on everything from kitchen countertops to phones. And with the depletion of supplies of hand sanitizer, also seen as a defense against COVID-19, demand has exploded to make homemade versions. The Food and Drug Administration and the World Health Organization list isopropyl alcohol as a critical ingredient in their recommended recipes.

So, for those with diabetes or other chronic medical conditions, the general public’s resulting panic-buying spree has threatened their medical routines, such as when patients use an alcohol swab or a rubbing alcohol-soaked cotton ball to disinfect their skin before they inject insulin.

Alternatives like witch hazel may not have the same antiviral properties, and the proof of most brands of vodka isn’t high enough to be effective. Other compounds, like hydrogen peroxide and liquid iodine, can be unwieldy for diabetes patients to manage while changing insulin pump sites on the go, Gregory said.

Despite the inability to obtain their usual products, people with diabetes still need to maintain their blood sugar levels, said Kelly Mueller, vice president of community impact at the American Diabetes Association. She encouraged patients to wash their hands and pump sites carefully and let them air-dry.

But in the midst of the coronavirus panic, the problem is compounded by a dearth of antibacterial soap or hand sanitizer to replace the disinfecting swabs or rubbing alcohol needed to keep prick sites clean, said Alison Dvorchik. She lives in Orlando, Florida, with her 17-year-old son, Matthew, who has Type 1 diabetes.

“I’m worried for the entire Type 1 diabetic community,” she said. “That’s a cesspool of infection waiting to happen.”

Any potential infection is a strain on an already overburdened health care system, Dvorchik said. For now, she’s trying to ward off that fate for Matthew with a stash of 100 alcohol wipes from a friend — they use about three a day with Matthew’s insulin pump.

The madness began about three weeks ago, according to New Jersey-based AvaCare Medical CEO Steven Zeldes, who runs one of the nation’s larger online medical supply companies.

Overnight his site was swamped with “thousands and thousands” of orders around the country for rubbing alcohol and rubbing alcohol swabs — medical supply items that had not been a primary focus for the company.

At first, he suspected some sort of pricing mishap. Then, he realized rubbing alcohol was a primary ingredient in making homemade hand sanitizer.

The tsunami of orders cleared out the warehouses of AvaCare Medical’s distributors in under two days. Zeldes said the company was out of stock so fast that it received thousands of orders before being able to take down the listings.

“Our company was always a medical supply company for seniors or nursing homes or hospitals,” Zeldes said. “Now we’re a company for every single citizen of America.”

Cathi Carothers, an operations assistant at Lab Alley, a chemical supplier in Austin, Texas, said her company saw a similar explosion of interest in alcohol products from fire departments and post offices as well as Tesla, the Department of Homeland Security and Johns Hopkins University.

“No one could have anticipated this much demand in a month,” Carothers said.

When Lab Alley called Dow and ExxonMobil — two of the largest raw-component manufacturers of isopropyl alcohol in the U.S. — to procure more, she said, the companies told Lab Alley they’re prioritizing hospitals.

Dow confirmed to KHN it was working with the FDA and state officials to maximize production of all its high-demand products. ExxonMobil directed KHN to a news release stating it was actively working with hard-hit New York and Louisiana to send isopropyl alcohol from its Baton Rouge Chemical Plant, which it says is “home to the world’s largest” isopropyl alcohol production site.

Both Medline, a major supplier in Chicago, and New Jersey-based Becton, Dickinson and Co., a health care product manufacturer and supplier, have felt the crush of demand. Medline spokesperson Stacy Rubenstein cited a 100% increase in March this year over last. Accordingly, both companies said they have ramped up production and enforced fair distribution measures.

Down the supply chain, Gregory, the Fayetteville woman with diabetes, said she lost it in line at Walgreens when she saw a sign saying the store was limiting customers to four bottles, which is more than she would go through in a year. (She uses it several times weekly to disinfect the sites of her insulin pump and every 10 days for her glucose monitor.)

“How much hand sanitizer are you making?” Gregory asked. “You certainly don’t need to be cleaning your kitchen with it — it’s not necessary. I think people are just panicking.”

Many forms of rubbing alcohol were sold out on Walgreens online site as of Sunday. Both Target and Rite Aid had also sold out of some rubbing alcohol and rubbing alcohol-related products online.

Finally, Gregory was able to snag one of the last orders for 100 wipes available through Healthcare Supply Pros, an online medical supply company. It should last her for about five months. She fears for older, poorer people with diabetes who may not have internet access or the money to do the same.

Plus, similar listings show the product is now sold out.

“Don’t hoard something that you don’t really need,” said Dvorchik, the mother of the teenager with diabetes. “Because the people who really need it can’t get it.”

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Trump Touted Abbott’s Quick COVID-19 Test. HHS Document Shows Only 5,500 Are On Way For Entire U.S.

A coronavirus test made by Abbott Laboratories and introduced with considerable fanfare by President Donald Trump in a Rose Garden news conference this week is giving state and local health officials very little added capacity to perform speedy tests needed to control the COVID-19 pandemic.

“That’s a whole new ballgame,” Trump said. “I want to thank Abbott Labs for the incredible work they’ve done. They’ve been working around-the-clock.”

Yet a document circulated among officials at the Department of Health and Human Services and the Federal Emergency Management Agency this week shows that state and local public health labs were set to receive a total of only 5,500 coronavirus tests from the giant manufacturer of medical devices, diagnostics and drugs, according to emails obtained by Kaiser Health News.

That number falls well short of the “about 500,000 capacity of Abbott tests that” Dr. Deborah Birx, the White House coronavirus response coordinator, said were in the states and were “not being utilized.” Although it is unclear if she was referring to the same Abbott assay.

Millions of tests are urgently needed as the virus keeps communities across the country in lockdown and hospitals are overwhelmed with patients.

Labs in all 50 states were set to receive roughly the same number of Abbott’s test cartridges and the devices on which they run ― 100 tests and 10 or 15 devices — the document shows, regardless of how many confirmed COVID-19 cases officials had reported in each state.

Abbott Labs spokesperson Darcy Ross on Thursday said the company had shipped tests to customers in 18 states but did not elaborate on how many were public clients or governments as opposed to private health care facilities. Ross also said the document circulated among federal officials showed an “intended purchase by HHS and FEMA” of tests and related instruments.

FEMA referred questions to HHS, whose spokesperson Mia Heck said, “We do not comment on any allegedly leaked documents.”

“We can confirm that the federal government is looking to make the initial purchase of a rapid point-of-care test to increase COVID-19 testing capacity in the United States,” she said. “Initially, each state will receive 15 point-of-care instruments, and then they will be able to resupply through the commercial market.”

Accuracy has been a broad problem in the testing for the novel coronavirus. Abbott Labs declined to address specifics on the clinical accuracy of its tests, which was fast-tracked through the Food and Drug Administration’s review process, saying that accuracy data and other performance characteristics will continue to be collected in the field.

State officials are scrambling to obtain Abbott’s highly touted machines after it said they could detect the novel coronavirus in as little as five minutes, or give a negative test result in about 13 minutes. That compares with at least 45 minutes to several days to get results from most of the other types of COVID-19 tests being used.

In announcing the test March 27, Abbott said it was “ramping up production to deliver 50,000 ID NOW COVID-19 tests per day” starting this week to the U.S. health care system.

The price of Abbott’s stock has jumped 26.5% since March 23.

The document circulated among HHS and FEMA officials March 30 and obtained by Kaiser Health News said 5,500 cartridges ― which translates to 5,500 tests — and 780 devices would be shipped to 55 state and local public health labs all over the U.S. An additional 1,200 tests would go to the Pacific territories. Smaller numbers would be sent to the CDC’s lab in Atlanta and the HHS’ Strategic National Stockpile.

Abbott has said the company is “working with the administration to deploy the tests to areas where they can have the greatest impact.”

But contrary to the document’s contents, distribution has been far from even. For example, within days of Abbott’s announcing it would ship its rapid test around the country, Detroit Mayor Mike Duggan said he had secured a commitment for five machines and 5,000 tests from the company, making it among the first cities to receive them. The city planned to immediately use them to test police officers and other first responders. A spokesperson for the city didn’t respond to questions Thursday about whether Detroit had the tests in hand.

“They tell me it’s extremely accurate,” Duggan said of the Abbott test Wednesday on CNN, adding it is supposed to be more accurate than the tests already available. “Right now, most of the tests we have are really not 90% accurate until the symptoms have shown themselves.”

Demand and hype for new tests developed by private companies surges with each new COVID-19 test that obtains emergency authorization from the FDA, but so far the results have been lackluster.

Since early February, the FDA has granted roughly two dozen emergency authorizations for clinical tests to detect the virus. The tests were developed by governments ― including the CDC and the New York state public health lab — and multiple private companies such as LabCorp, Quest Diagnostics, Roche Diagnostics and Thermo Fisher Scientific.

Yet providers have reported rampant problems with COVID-19 tests giving false negatives, in which the virus is not detected even in an infected person.

Few medical tests are 100% accurate. Any test can have false negatives or false positives. The problem isn’t unique to COVID-19 tests.

“False-negative test results — tests that indicate you are not infected, when you are — seem to be uncomfortably common,” Dr. Harlan Krumholz, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, wrote in a New York Times piece April 1. “Increasingly, and disturbingly, I hear a growing number of anecdotal stories from my fellow doctors of patients testing negative for coronavirus and then testing positive — or people who are almost certainly infected who are testing negative.”

Reasons for this can vary. The test itself might not be so good at picking out true cases from false ones. Or maybe it wasn’t the test at all, but how the sample was taken or how long it had been since the patient began showing symptoms. Doctors and patients should always consider that a result might not be accurate.

That may be especially true now because the COVID-19 test kits from manufacturers and clinical labs became available under emergency use rules.

Under those rules, manufacturers and labs have to submit documentation to the FDA but don’t have to provide as much information as they would under a regular approval process.

Part of the requirement is they show the FDA just how much ― or little — of the virus must exist in the samples before their test can detect it, said Joeffrey Chahine, technical director for the molecular pathology division at MedStar Georgetown University Hospital in Washington, D.C.

They also must show how well the tests specifically pick out the coronavirus, not confusing it with another virus, he said.

By relaxing some of the other information normally required, such as correlating results with the status of actual patients, the test kits could get onto the market sooner. And that’s the trade-off.

“This is the downside to loosening the FDA restrictions in that the tests weren’t required to go through the same level of quality assurance, the testing of the test, that we would normally see before they go on the market,” said Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials. “But I don’t think that was a bad decision. This is an emergency.”

Detroit, which was supposed to get thousands of Abbott tests this week, had more than 2,800 confirmed COVID-19 cases and 97 deaths as of Thursday evening, and is part of the next wave of emerging hot spots around the country, along with New Orleans and parts of Georgia.

Abbott said it would make tests available to health care providers in “urgent care settings” in the U.S. already using its testing platform, but would not elaborate on specifics.

Public health officials in New York City, Oklahoma and Louisiana said Thursday they had not received the Abbott tests.

“We’re aware we didn’t have an accurate picture,” Shelley Zumwalt, Oklahoma’s chief of innovation, said generally of Oklahoma’s slow testing start. That has begun to change due to increased testing at Oklahoma State University as well as drive-thru testing sites in over a dozen locations in the state.

Others said that even if they had the Abbott tests, they weren’t likely to make much of a dent.

“Each cartridge is one test, and the number of patients you can test depends on how many you use up for training and verification, and quality control, which needs to be run at least once a day,” said New York City Department of Health and Mental Hygiene spokesperson Stephanie Buhle. “So 100 cartridges will not go very far.”

KHN senior correspondent Julie Appleby contributed to this report.

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Pandemic-Stricken Cities Have Empty Hospitals, But Reopening Them Is Difficult

As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.

In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city’s poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.

Philadelphia, the largest city in America with no public hospital, is also the poorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building’s owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city’s capacity. Not long after negotiations started, city officials announced the talks were going badly.

“Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital,” said Brian Abernathy, who is Philadelphia’s managing director and heading the city’s COVID-19 response.

In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city’s new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being converted to a “step-down” facility with the capacity to treat up to 2,000 patients after they no longer need critical care.

Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.

In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.

“I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn’t thinking through what the impacts are on public health,” Abernathy said of Freedman. “I think he’s looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents.”

This isn’t the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn’t try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann’s real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System’s Chapter 11 bankruptcy petition.

A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.

“We’re offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner,” said Broad Street representative Sam Singer.

As urban hospitals have struggled in recent years, it’s become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.

In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.

“The house never loses,” said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. “The private equity firm makes money whether the company succeeds or it doesn’t.”

For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to Iasis, another private equity-owned company, on all its properties, while also struggling to stay in the black. The network announced last week it would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.

Freedman’s private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.

Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.

“If your urban hospital is purchased by a for-profit company and it doesn’t perform sufficiently, they don’t have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss,” said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.

Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.

Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.

“Eminent Domain was created for situations like #Hahnemann,” City Council member Helen Gym wrote on Twitter. “This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property.” Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.

But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn’t had to happen ― at least not in the traditional sense.

In Pennsylvania, the governor’s emergency declaration gives him the authority to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.” A health department representative said all options remain on the table in the event that the city’s hospital bed capacity is overrun.

In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

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KHN’s ‘What The Health?’: All Coronavirus All The Time


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


The medical and economic needs laid bare by the coronavirus pandemic are forcing some immediate changes to the U.S. health system. Congress, in its latest relief bill, provided $100 billion in funding for the hospital industry alone. Meanwhile, the federal government has quickly removed previous barriers to telehealth and other sometimes controversial practices.

But big fights are still brewing, including whether the federal government will reopen the Affordable Care Act marketplaces it runs and whether states can use emergency powers to ban abortions as “elective medical procedures.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The ACA was passed on the heels of the Great Recession. The coronavirus outbreak has produced the first big economic downturn since then, and the law’s provisions to expand Medicaid and to provide an insurance option to those without jobs could provide a critical safety net during this crisis.
  • About a dozen states running their own ACA insurance marketplaces have opened up enrollment again to let people who did not enroll in the fall but are feeling the pinch from the coronavirus pandemic to reconsider. President Donald Trump said this week that he is mulling a similar move, but the messages from the administration on such action have been confusing.
  • People who had insurance through work and have lost their jobs don’t need a special enrollment period to sign up for an Obamacare plan. They are eligible because their job situation changed. However, the administration has not been publicizing that message.
  • Hospitals are eager to receive the $100 billion appropriated by Congress in response to the influx of patients with COVID-19, the disease caused by the coronavirus. But the administration has not yet said how that money will be apportioned.
  • A handful of states have prohibited abortions during the coronavirus emergency because, officials say, they are seeking to preserve protective gear for hospital staff treating COVID-19 patients. But it’s not clear that the abortion procedures ― especially medication abortions — are interfering with efforts to safeguard protective clothing or masks needed by hospitals. And women who do not get abortions will consume far more medical care by remaining pregnant and giving birth.

Also, this week, Rovner interviews KHN’s Liz Szabo, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who underwent a very expensive genetic test. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “A Ventilator Stockpile With One Hitch: Thousands Do Not Work,” by David E. Sanger, Zolan Kanno-Youngs and Nicholas Kulish

Joanne Kenen: The New Yorker’s “The Life and Death of Juan Sanabria, One of New York City’s First Cornavirus Victims,” by Jonathan Blitzer

Margot Sanger-Katz: Bloomberg News’ “Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear,” by Olivia Carville, Emma Court and Kristen V. Brown

Alice Miranda Ollstein: The Washington Post’s “Trump Ban on Fetal Tissue Research Blocks Coronavirus Treatment Effort,” by Amy Goldstein


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