Tag: States

March 27, 2023

When College Athletes Kill Themselves, Healing the Team Becomes the Next Goal

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing “988,” or the Crisis Text Line by texting “HOME” to 741741.

In the weeks after Stanford University soccer goalie Katie Meyer, 22, died by suicide last March, her grieving teammates were inseparable even when not training.

Coaches adjusted practices to give the athletes time and space to make sense of losing their friend and team captain. They offered to cancel the spring season, but the players declined, said Melissa Charloe, who started as a Stanford assistant women’s soccer coach the day Meyer died.

“It’s hard because there’s no playbook on how to do this,” Charloe said.

No playbook exists because, until recently, it was relatively uncommon for student-athletes to die by suicide. But at least five NCAA athletes, including Meyer, ended their lives in a two-month period last year. And a 2021 NCAA poll released in May found that student-athletes say they are experiencing more mental health concerns, anxiety, and depression than they reported in surveys conducted before the covid-19 pandemic took hold in 2020.

Suicide is the second-leading cause of death on college campuses. And despite the overall rise in mental health concerns there, universities have been caught off guard when student-athletes have died by suicide. Traditionally, sports psychologists focused on mental health as it related to performance on the field. Their goal was to help athletes improve physically — jump higher, run faster — not navigate mental health crises, largely because of a misperception that college athletes were less susceptible to mental health concerns.

What little research exists about student athletes and mental health is inconsistent and inconclusive. But many experts thought athletes were insulated from risk factors such as depression and social isolation, in part because physical activity is good for mental health and athletes have a steady stream of people around them, including coaches, trainers, and teammates, said Kim Gorman, director of counseling and psychological services at Western Carolina University.

“They’re kind of used to pain — it’s not so foreign to them,” added organizational psychologist Matt Mishkind, deputy director of the Helen and Arthur E. Johnson Depression Center at the University of Colorado’s Anschutz Medical Campus.

Still, athletes face pressures that their peers in the general student population don’t, such as balancing sports, schoolwork, fears of career-ending injuries, and mistakes that can lead to ridicule that gets amplified on social media. With suicide rates in the general population on the rise and the effects of the pandemic continuing to threaten well-being, high-profile suicides highlight how to deal with the unthinkable — and how to try to prevent it from happening again.

In the wake of such suicides, schools are reevaluating the kind of mental health support they provide. Creating a safe space to talk about grief with someone who understands suicide is a critical first step, said psychologist Doreen Marshall, a vice president at the American Foundation for Suicide Prevention.

“Many professionals are good with grief, but suicide grief can be a little different,” she said, as it often involves guilt and questions about why someone would end their life.

Gina Meyer, Katie’s mother, and her husband, Steve, have developed an initiative, Katie’s Save, to ensure that all students have a trusted advocate to turn to in times of trouble. “We know that the bravest thing you can do is ask for help,” she said.

The Meyers filed a wrongful death lawsuit against Stanford in November alleging that their daughter ended her life after receiving an email from the university about disciplinary action against her. Stanford University spokesperson Dee Mostofi did not answer questions about the case, but Stanford posted a statement on its website saying the Meyers’ suit contains misleading information and the school disagrees with their allegations that it is responsible for Katie’s death.

“Like other colleges and universities across the country, Stanford has seen a sharp increase in demand for mental health counseling and other well-being resources over the last two years,” Mostofi said. “Mental health remains not only an ongoing challenge but our most urgent priority.”

After Meyer died, Stanford provided mental health counselors and a sports psychologist to her teammates, but the players said they lobbied the university to pay for Zoom sessions with a specialist, Kimberly O’Brien, a clinical social worker in the Sports Medicine Division’s Female Athlete Program at Boston Children’s Hospital.

O’Brien has professional and personal experience dealing with sports and suicide: She was an ice hockey player at Harvard in 1998 when one of the athletes in her university house died. “I wasn’t even extremely close to her, but it affected me profoundly,” she said. “There were no resources to deal with it.”

That’s changing. Colleges are trying to hire more mental health therapists to meet increasing and varied needs. Some, including Stanford and Washington State University, are working with The Jed Foundation, which provides suicide prevention programming for high school and college students. And crisis support doesn’t happen just in the student health center: Colleges are establishing campus-wide “postvention” programs to prevent suicide contagion.

After Stanford University soccer goalie Katie Meyer died by suicide in March 2022, her grieving teammates were inseparable. The coaches adjusted practice schedules and asked the team members if they wanted to cancel the season, but they wanted to keep playing. “It’s hard because there’s no playbook on how to do this,” assistant coach Melissa Charloe says. (Tyler Geivett/Stanford Athletics)

Before cross-country runner Sarah Shulze, 21, died by suicide at the University of Wisconsin-Madison in April 2022, the athletics department was expanding its professional mental health support from two staffers to six to help the school’s approximately 800 student-athletes, said David Lacocque, the department’s director of mental health and sport psychology. The department, known until eight months ago as “clinical & sport psychology,” changed its name in part because student-athletes were asking for mental health support.

In addition to scheduled appointments, the sports liaisons attend practices, team meetings, training sessions, and competitions to help normalize mental health concerns.

“Gone are the days when we sit in our office and wait for people to knock on the door and talk to us,” Lacocque said.

Student-athletes can also seek free help from the university’s mental health professionals or providers in the community under contract with the University of Wisconsin athletics department. And some women’s cross-country athletes at the school now keep an eye on their teammates when coaches aren’t around, letting the team’s liaison know if they’re concerned about someone’s mental health.

“We don’t want anyone slipping between the cracks,” said teammate Maddie Mooney. “It’s a hard time for everybody, and everybody grieves at different paces and processes things differently.”

Teammate Victoria Heiligenthal, who shared a house with Shulze, said she avoided talking to campus counselors for months after her close friend died. “I only wanted to be alone or be with my friends who really understood the situation,” she said.

Heiligenthal couldn’t bear to stay in the home where she and Shulze had lived, so the university put her and Mooney up in a hotel for a week, and then she stayed awhile at Mooney’s apartment. Once back in her own place, teammates, coaches, training staff, and psychologists checked in on her and Mooney.

But the real game changer for the two was connecting last spring with Stanford soccer players Sierra Enge and Naomi Girma (who now plays professionally). Enge reached out after seeing something Mooney posted on Instagram. Since then, the four have met via Zoom. They have also talked with O’Brien and will join her on a mental health panel at a conference in Boston in June to talk about their experiences of losing a teammate to suicide.

“It was powerful hearing the parallels,” Heiligenthal said. “It made you realize Maddie and I weren’t alone; there were others who were experiencing similar things to us.”

At the University of Wisconsin-Madison and Stanford, athletes honored their late teammates last fall by raising mental health awareness. At a major meet in October, the Wisconsin runners painted green ribbons on the course, put ribbons in race packets, and contributed to a video. At Stanford’s game against UCLA in November, spectators wore green ribbons to highlight the importance of addressing mental health issues.

Stanford won the game, handing UCLA its first loss of the season. The victory was bittersweet. A year earlier, Meyer had spearheaded the team’s first mental health awareness game.

March 25, 2023

Journalists Delve Into Insulin Costs and Prior Authorization Policy

KHN senior correspondent Angela Hart discussed California’s contract with Civica to make lower-cost insulin on KQED’s “Forum” on March 23. She also discussed California’s potential plan to use Medicaid funding to cover up to six months of rent for low-income enrollees on KCBS’ “State of California” on March 22.

KHN South Carolina correspondent Lauren Sausser discussed prior authorization on WNHN’s “The Attitude With Arnie Arnesen” on March 21.

KHN Montana legislative fellow Keely Larson discussed Montana’s vaccine exemption legislation on the Montana Free Press’ “The Session” on March 20.

KHN Midwest correspondent Bram Sable-Smith discussed insulin costs on NPR’s “Weekend Edition Saturday” on March 18.

March 24, 2023

Health Providers Scramble to Keep Remaining Staff Amid Medicaid Rate Debate

Andrew Johnson lets his clients choose what music to play in the car.

As an employee of Family Outreach in Helena, Montana — an organization that assists developmentally disabled people — part of his workday involves driving around, picking up clients, and taking them to work or to run errands.

“What’s up, gangsta?” Johnson said as a client got in the car one day in March.

The pair fist-bumped and Johnson asked what type of music the client liked.

“Gangsta stuff,” came the response. Rap, mainly.

Snoop Dogg played in the background as Johnson and his client drove to McDonald’s, where Johnson helps his client work. The duo washed dishes for two hours in the back of the fast-food restaurant, where it smelled like maple syrup and sulfur.

About two weeks earlier, Johnson testified at a hearing at the Montana Capitol in support of a bill that seeks to raise health providers’ Medicaid reimbursement rates to levels aligned with the average cost of the care they provide. The bill is informed by a 2022 study that recommended benchmark rates after its authors found that Montana Medicaid providers like Family Outreach were being significantly underpaid.

“The provider rates need to be funded so people that work in this field or that work in adjacent fields can have solid ground, a place where you can build a career,” said Johnson, who makes $16.24 per hour in his position as an individual living specialist.

Republican Gov. Greg Gianforte and legislators agree that Medicaid rates need to rise; where they disagree is by how much. The proposals range from the bill Johnson testified for — Democratic Rep. Mary Caferro’s bill to raise rates to the study’s benchmarks — to Gianforte’s plan to fund 91% of that benchmark in 2024 and 86% in 2025.

Meanwhile, the Republicans leading the House Appropriations Committee, a key budget panel, are proposing an average increase of 92% for fiscal year 2024 and 97% in 2025.

Andrew Johnson says his friends think he’s crazy for deciding to work in human services. He knows he made the right career choice for himself, but he still wants to be able to afford a house in Montana someday. (Keely Larson)

Providers and leaders who work in behavioral health, developmental disability, long-term care, and family support services have attended the multiple hearings on rate adjustments, saying thanks for the proposed increases but asking for more. Many providers said the benchmark rates in the study are already outdated.

Providers across the United States say they haven’t seen significant reimbursement increases in more than a decade, according to Shawn Coughlin, president of the National Association for Behavioral Healthcare. Behavioral health can be an afterthought for policymakers, resulting in lower rates than for medical or surgical reimbursement, he said

Michael Barnett, associate professor of health policy and management at the Harvard T.H. Chan School of Public Health, said the supply of staff is inadequate to meet demand for behavioral health care across the U.S.

“And it’s not clear we’re going to meet any of that without paying people more,” Barnett said.

Some health providers have raised wages but still struggled to draw workers and keep the ones they’ve got. Family Outreach raised the wages of some direct care workers from $11 per hour to $12.20 per hour this year, and by more in places where the cost of living is higher, such as Bozeman. But even starting wages of $16 or $18 an hour aren’t attracting enough people to work there, Family Outreach Program Manager Tyler Tobol said.

“It’s a field that not a lot of people want to get into, so those that we can find, I think being able to pay a higher wage, a living wage, I think that would be the best benefit we get out of the rate increase,” Tobol said.

The organization went from 153 employees in 2020 to 128 today. The staffing shortage means employees now focus mainly on making sure clients have the basics — medications and meals — instead of providing additional community integration and activity support services.

At Florence Crittenton in Helena, where moms 18 to 35 with substance use disorders can live with their young kids while undergoing treatment, a mom entered the kitchen where women are taught life skills like learning to cook dinner. The woman told a staff member she was making juice for her child.

“This is where life happens,” said Daniel Champer, Florence Crittenton’s clinical and residential services director.

Executive Director Carrie Krepps said the organization’s two main sources of revenue are Medicaid reimbursements and fundraising. Fundraising, which used to account for 30% of revenue, now makes up between 60% and 70% of the money coming in.

“It’s the reason we’re still open,” Krepps said.

Florence Crittenton’s youth maternity wing has been closed since November 2021 due to staffing difficulties. Previously, teens ages 12-15 stayed in the apartments and received support services from Florence Crittenton. (Keely Larson)

Andrew Johnson says a lot of people with developmental disabilities go to Van’s Thriftway in Helena to get checks cashed. He describes Van’s as an inclusive grocery store. (Keely Larson)

At any given time, an average of 15 to 18 of Florence Crittenton’s 50 staff positions are vacant. If Medicaid rates don’t increase, she said, the organization will have to consider if it can continue operating the recovery home at its current capacity.

“The full rates would just barely cover where we are today,” Krepps said of raising Medicaid reimbursement rates to benchmark levels.

In 2021, Florence Crittenton closed a youth maternity home for pregnant youths and young moms ages 12 to 15, the only home in the state that took teens under 16. Krepps said Florence Crittenton didn’t take Medicaid fees there because the rates were too low.

“It’s heartbreaking,” Champer said. “It’s like clockwork on Monday morning. I come in and see the inquiries and referrals about moms who need treatment and we can’t function at full capacity because we don’t have staff.”

Dennis Sulser, the CEO of Youth Dynamics, which provides home support, case management, and community-based psychiatric rehabilitation across the state, said his organization is paying its staff more than it can afford. Even with the rate increase, he said, they’d only break even.

In the past three years, Youth Dynamics has lost 56 full-time employees. The covid-19 pandemic made people realize they could find other jobs that paid more and even allowed them to stay home, Sulser said.

Andrew Johnson transports a client from his group home to Family Outreach, where the client does janitorial work for the organization. Johnson described this client as his “soul animal,” referring to their similar taste in music. (Keely Larson)

Two years ago, the entry-level pay for Youth Dynamics was $10.70 per hour, and it now averages $13.70. Still, staffing shortages led to the closure of a group home in Boulder and one in Billings, shrinking the organization’s capacity from 80 to 64 beds statewide.

Ashley Santos, program manager for the organization’s three remaining group homes in Boulder, said she is trying to figure out how to attract enough staff to reopen the closed home there. An increase in pay supported by the provider rate increase could give her flexibility to provide extra incentives, she said.

But it’s hard to attract workers when Hardee’s has a starting wage of $18 per hour compared with Youth Dynamics’ $16, she said. And fast-food jobs don’t come with the emotional toll of working with kids who have a severe emotional disturbance diagnosis like PTSD or depression.

Back in Helena, Johnson made his last stop of the day for Family Outreach. He sat next to a client on the couch at the house where the client lives with his mom. Johnson called the number on the back of his client’s debit card to see how much money was left on it before they went out to run errands.

Johnson and the client then headed to a local supermarket. Trips like these give his client a chance to interact with other people, while his mom gets some time to herself.

“You look nice,” Johnson said to the client as they got into the car, the folksy music of Dougie Poole, the choice of Johnson’s previous client, playing in the background.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

March 23, 2023

Fresh Produce Is an Increasingly Popular Prescription for Chronically Ill Patients

When Mackenzie Sachs, a registered dietitian on the Blackfeet Reservation, in northwestern Montana, sees a patient experiencing high blood pressure, diabetes, or another chronic illness, her first thought isn’t necessarily to recommend medication.

Rather, if the patient doesn’t have easy access to fruit and vegetables, she’ll enroll the person in the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access to reduce their cost for healthy foods. Since 2021, Sachs has recommended a fruit-and-vegetable treatment plan to 84 patients. Increased consumption of vitamins, fiber, and minerals has improved those patients’ health, she said.

“The vouchers help me feel confident that the patients will be able to buy the foods I’m recommending they eat,” she said. “I know other dietitians don’t have that assurance.”

Sachs is one of a growing number of health providers across Montana who now have the option to write a different kind of prescription — not for pills, but for produce.

The Montana Produce Prescription Collaborative, or MTPRx, brings together several nonprofits and health care providers across Montana. Led by the Community Food & Agriculture Coalition, the initiative was recently awarded a federal grant of $500,000 to support Montana produce prescription programs throughout the state over the next three years, with the goal of reaching more than 200 people across 14 counties in the first year.

Participating partners screen patients for chronic health conditions and food access. Eligible patients receive prescriptions in the form of vouchers or coupons for fresh fruits and vegetables that can be redeemed at farmers markets, food banks, and stores. During the winter months, when many farmers markets close, MTPRx partners rely more heavily on stores, food banks, and nonprofit food organizations to get fruits and vegetables to patients.

The irony is that rural areas, where food is often grown, can also be food deserts for their residents. Katie Garfield, a researcher and clinical instructor with Harvard’s Food is Medicine project, said produce prescription programs in rural areas are less likely than others to have reliable access to produce through grocers or other retailers. A report from No Kid Hungry concluded 91% of the counties nationwide whose residents have the most difficulty accessing adequate and nutritious food are rural.

“Diet-related chronic illness is really an epidemic in the United States,” Garfield said. “Those high rates of chronic conditions are associated with huge human and economic costs. The idea of being able to bend the curve of diet-related chronic disease needs to be at the forefront of health care policy right now.”

An example of a voucher for fresh produce distributed by the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access on the Blackfeet reservation. (FAST Blackfeet)

Produce prescription programs have been around since the 1960s, when Dr. Jack Geiger opened a clinic in Mound Bayou, a small city in the Mississippi Delta. There, Dr. Geiger saw the need for “social medicine” to treat the chronic health conditions he saw, many the result of poverty. He prescribed food to families with malnourished children and paid for it out of the clinic’s pharmacy budget.

A study by the consulting firm DAISA Enterprises identified 108 produce prescription programs in the U.S., all partnered with health care facilities, that launched between 2010 and 2020, with 30% in the Northeast and 28% in the Midwest. Early results show the promise of integrating produce into a clinician-guided treatment plan, but the viability of the approach is less proven in rural communities such as many of those in Montana.

In Montana, 31,000 children do not have consistent access to food, according to the Montana Food Bank Network. Half of the state’s 56 counties are considered food deserts, where low-income residents must travel more than 10 miles to the nearest supermarket — which is one definition the U.S Department of Agriculture uses for low food access in a rural area.

Research shows long travel distances and lack of transportation are significant barriers to accessing healthy food.

“Living in an agriculturally rich community, it’s easy to assume everyone has access,” said Gretchen Boyer, executive director of Land to Hand Montana. The organization works with nearby health care system Logan Health to provide more than 100 people with regular produce allotments.

“Food and nutritional insecurity are rampant everywhere, and if you grow up in generational poverty you probably haven’t had access to fruits and vegetables at a regular rate your whole life,” Boyer said.

More than 9% of Montana adults have Type 2 diabetes and nearly 35% are pre-diabetic, according to Merry Hutton, regional director of community health investment for Providence, a health care provider that operates clinics throughout western Montana and is one of the MTPRx clinical partners.

Brittany Coburn, a family nurse practitioner at Logan Health, sees these conditions often in the population she serves, but she believes produce prescriptions have tremendous capacity to improve patients’ health.

“Real food matters and increasing fruits and veggies can reverse some forms of diabetes, eliminate elevated cholesterol, and impact blood pressure in a positive way,” she said.

Mackenzie Sachs, a registered dietitian, and Thedra Bird Rattler, a nutrition education specialist, work for FAST Blackfeet. (FAST Blackfeet)

Produce prescription programs have the potential to reduce the costs of treating chronic health conditions that overburden the broader health care system.

“If we treat food as part of health care treatment and prevention plans, we are going to get improved outcomes and reduced health care costs,” Garfield said. “If diet is driving health outcomes in the United States, then diet needs to be a centerpiece of health policy moving forward. Otherwise, it’s a missed opportunity.”

The question is, Do food prescription initiatives work? They typically lack the funding needed to foster long-term, sustainable change, and they often fail to track data that shows the relationship between increased produce consumption and improved health, according to a comprehensive survey of over 6,000 studies on such programs.

Data collection is key for MTPRx, and partners and health care providers track how participation in the program influences participants’ essential health indicators such as blood sugar, lipids, and cholesterol, organizers said.

“We really want to see these results and use them to make this more of a norm,” said Bridget McDonald, the MTPRx program director at CFAC. “We want to make the ‘food is medicine’ movement mainstream.”

Sachs acknowledged that “some conditions can’t usually be reversed,” which means some patients may need medication too.

However, MTPRx partners hope to make the case that produce prescriptions should be considered a viable clinical intervention on a larger scale.

“Together, we may be able to advocate for funding and policy change,” Sachs said.

March 23, 2023

Legal Questions, Inquiries Intensify Around Noble Health’s Rural Missouri Hospital Closures

A year after private equity-backed Noble Health shuttered two rural Missouri hospitals, patients and former employees grapple with a broken local health system or missing out on millions in unpaid wages and benefits.

The hospitals in Audrain and Callaway counties remain closed as a slew of lawsuits and state and federal investigations grind forward.

In March, Missouri Attorney General Andrew Bailey confirmed a civil investigation. He had previously told local talk radio that there was an “ongoing” investigation into “the hospital issue.”

Bailey’s comment came weeks after the U.S. Department of Labor’s Employee Benefits Security Administration notified executives tied to Noble Health, a startup, that they had violated federal laws and asked them to pay $5.4 million to cover unpaid employee health insurance claims, according to a 13-page letter detailing “interim findings” that was obtained by KHN.

The January letter confirms KHN’s previous reporting, which was informed by employees and patients who described missing paychecks; receiving unexpected, high-dollar medical bills; and going without care, including cancer treatment. According to the letter from federal investigators, the Noble hospitals and their corporate owners collected employee contributions for medical, dental, and vision insurance in 2021 and 2022 but then failed to fund the insurance plans.

The owners and executives were “aware of the harm to participants and, in some cases, were attempting to resolve individual participant complaints,” the letter states, adding that “despite the volume and gravity of complaints and bills received,” they failed to respond.

A photo of a two-year-old boy with spina bifida in a walker. — Ryder Hagedorn was born with spina bifida. His parents have struggled to pay for specialty care since claims were denied by a health plan his mother, Marissa, was offered through her employer. She is one of several former employees of Noble Health who say they were left with substantial medical bills after the company shuttered its two rural Missouri hospitals.(Marissa Hagedorn)

‘Tomfoolery’ and Doing ‘Everybody Dirty’

Marissa Hagedorn, who worked as a hospital laboratory technician, has spent much of the past year starting a new job, caring for her 2-year-old son who was born with spina bifida, and haggling over unpaid medical bills. She told KHN the family owes at least $8,000 for son Ryder’s specialty care in St. Louis, with $6,000 of that in collections. As a Noble employee, Hagedorn said, she was told repeatedly that her employee health insurance would cover Ryder’s care. It didn’t.

Noble has “done everybody dirty,” she said. “We just would like for some responsibility to be taken by this company that didn’t feel the need to get their act together.” Hagedorn’s story of unpaid bills, which was first reported by the local newspaper, the Mexico Ledger, is common among former Noble employees a year after the hospitals closed.

A former employee of the Fulton hospital has filed a class-action lawsuit intended to represent hundreds of employees from both hospitals.

The Jan. 13 letter from federal officials called for responses by Jan. 27 from Noble corporate and hospital executives as well as Platinum Neighbors, which last April bought the hospitals and assumed all liabilities. The letter instructs executives to contact the agency “to discuss how you intend to correct these violations, fund participant claims, and achieve compliance.”

Former employees say their claims have not yet been paid. A Labor Department spokesperson, Grant Vaught, said the agency could not comment on an ongoing investigation.

Separately, the Kansas Department of Labor is reviewing Noble and Platinum’s failure to pay wages and severance to corporate employees. Agency spokesperson Becky Shaffer confirmed that hearings took place in early February on a half-dozen cases totaling more than $1 million in claims for unpaid wages and severance.

Dave Kitchens was among those who filed claims against Noble Health. Kitchens worked briefly as a contract employee and then was hired in October 2021 as a corporate controller, an accounting role in which he was responsible for financial reporting and data analytics. Kitchens provided an audio recording of his hearing to KHN and hopes to eventually get paid more than $90,000 in lost wages, benefits, and severance pay. During the hearing, Kitchens told the administrative judge: “I would just like to be paid what I’m owed.”

Kitchens, who is also named as a fiduciary on the federal investigation, said he was not on Noble’s executive team. When asked by Kansas Administrative Law Judge James Ward whether he expected Noble or the secondary buyer Platinum to pay his wages, Kitchens responded he had “no idea who was in charge.”

“I believe there was some tomfoolery,” Kitchens said.

A ‘Rabbit Hole’ of Responsibility

Noble launched in December 2019 with executives who had never run a hospital, including Donald R. Peterson, a co-founder who prior to joining Noble had been accused of Medicare fraud. Peterson settled that case without admitting wrongdoing and in August 2019 agreed to be excluded for five years from Medicare, Medicaid, and all other taxpayer-funded federal health programs, according to the Health and Human Services Office of Inspector General.

By March 2022, the hospitals had closed and Noble offered explanations on social media, including “a technology issue” and a need to “restructure their operations” to keep the hospitals financially viable. In April, Texas-based Platinum Neighbors paid $2 for the properties and all liabilities, according to the stock purchase agreement.

Despite receiving approval for nearly $20 million in federal covid-19 relief money before it closed the hospitals — funds whose use is still not fully accounted for — Noble had stopped paying its bills, according to court records. Contractors, including nursing agencies, a lab that ran covid tests and landscapers, have filed lawsuits seeking millions.

In Audrain County, where community members still hope to reopen the hospital or build a new one, county leaders filed suit for the repayment of a $1.8 million loan they made to Noble. Former Missouri state senator Jay Wasson also filed suit in September, asking for repayment of a $500,000 loan.

Two Noble Health real estate entities filed bankruptcy petitions this year. One Chapter 11 bankruptcy filing names the Fulton hospital property in Callaway County as an asset and lists nearly $4.9 million in liabilities. A third bankruptcy filing by FMC Clinic includes Noble Health as a codebtor.

In the U.S. District Court of Kansas, Central Bank of the Midwest is suing Nueterra Capital over a $9.6 million loan Noble used to buy the Audrain hospital. The bank alleges Nueterra, a private equity and venture capital firm that in 2022 included Noble as part of its portfolio, signed off as the guarantor of the loan.

Federal investigators listed nearly a dozen people or entities connected to Noble Health as fiduciaries who they say are personally responsible for paying back millions in unpaid medical claims. The letter also detailed Noble Health’s ownership for the first time. The owners included William A. Solomon with a 16.82% share, Thomas W. Carter with a 16.82% share, The Peterson Trust with a 19.63%, and NC Holdings Inc. with 46.72%.

NC Holdings is also listed on the stock sale agreement with Platinum along with several signatures including Jeremy Tasset, chief executive of Nueterra Capital.

Tasset did not respond to a request for comment for this article. In an email to KHN in March 2022, the Nueterra Capital CEO wrote, “We are a minority investor in the real estate and have nothing to do with the operations of the hospitals.” In May 2022, Tasset wrote in an email to KHN that “everything was sold (real estate included) to Platinum Neighbors, a subsidiary of Platinum Team Management.”

It is unclear who owns and controls The Peterson Trust, which federal investigators identified. Peterson, who is listed on Noble’s state registration papers as a director and in other roles, didn’t respond to requests for comment for this article. He previously told KHN that his involvement in Noble didn’t violate his exclusion, in his reading of the law.

He said he owned 3% of the company, citing guidance from the Office of Inspector General for the U.S. Department of Health and Human Services. Federal regulators may exclude companies if someone who is banned has ownership of 5% or more.

In March 2022, Peterson created Noble Health Services, which federal investigators note in their letter was “established to restructure the ownership of multiple Noble entities.” Peterson dissolved that company in July 2022, according to a Missouri business filing.

In September, Peterson posted on LinkedIn that he was “sitting in the Emirates Air lounge in Dubai” to finish up due diligence on “launching a new business.”

A 2013 OIG advisory states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.”

KHN examined the federal system meant to stop health care business owners and executives from repeatedly bilking government health programs and found that it failed to do so.

The OIG keeps a public list of people and businesses it has banned from all federal health care programs, such as Medicare and Medicaid. KHN’s review found a system devoid of oversight and rife with legal gray areas.

In the wake of KHN’s reporting, Oregon Sen. Ron Wyden, a Democrat who is the chair of the powerful Senate Finance Committee, said “it’s imperative that federal watchdogs can ensure bad actors are kept out of Medicare.” Sen. Chuck Grassley (R-Iowa) said the government needs to do more and “it’s also up to private-sector entities to do a better job checking against the exclusions list.”

“We can’t just depend on one or the other to do everything,” Grassley said.

In recent months, the Missouri hospitals appear to have been sold twice more, according to public records. Oregon-based Saint Pio of Pietrelcina notified state officials of a change of ownership in December and requested an extension of the hospital licenses, which was denied. In January, Audrain County officials, in its lawsuit, revealed another owner named Pasture Medical, which registered as a Wyoming company on Dec. 27, 2022.

“We haven’t come out of the rabbit hole on this one,” said Steve Bollin, director of the division of regulation and licensure for the Missouri Department of Health and Senior Services. Bollin’s agency, which conducts inspections and approves hospital changes in ownership, said he would support his agency doing financial reviews.

“It’s probably not a bad idea that someone takes a little bit deeper dive. We don’t have that many changes of ownership, but we would need appropriate staffing to do that, including some really good CPAs [certified public accountants].”

March 22, 2023

Prescription for Housing? California Wants Medicaid to Cover 6 Months of Rent

SACRAMENTO, Calif. — Gov. Gavin Newsom, whose administration is struggling to contain a worsening homelessness crisis despite record spending, is trying something bold: tapping federal health care funding to cover rent for homeless people and those at risk of losing their housing.

States are barred from using federal Medicaid dollars to pay directly for rent, but California’s governor is asking the administration of President Joe Biden, a fellow Democrat, to authorize a new program called “transitional rent,” which would provide up to six months of rent or temporary housing for low-income enrollees who rely on the state’s health care safety net — a new initiative in his arsenal of programs to fight and prevent homelessness.

“I’ve been talking to the president. We cannot do this alone,” Newsom told KHN.

The governor is pushing California’s version of Medicaid, called Medi-Cal, to fund experimental housing subsidies for homeless people, betting that it’s cheaper for taxpayers to cover rent than to allow people to fall into crisis or costly institutional care in hospitals, nursing homes, and jails. Early in his tenure, Newsom proclaimed that “doctors should be able to write prescriptions for housing the same way they do for insulin or antibiotics.”

But it’s a risky endeavor in a high-cost state where median rent is nearly $3,000 a month, and even higher in coastal regions, where most of California’s homeless people reside. Experts expect the Biden administration to scrutinize the plan to use health care money to pay rent; and also question its potential effectiveness in light of the state’s housing crisis.

“Part of the question is whether this is really Medicaid’s job,” said Vikki Wachino, who served as national Medicaid director in the Obama administration. “But there is a recognition that social factors like inadequate housing are driving health outcomes, and I think the federal government is open to developing approaches to try and address that.”

Bruce Alexander, a spokesperson for the Centers for Medicare & Medicaid Services, declined to say whether the federal government would approve California’s request. Yet, Biden’s Medicaid officials have approved similar experimental programs in Oregon and Arizona, and California is modeling its program after them.

California is home to an estimated 30% of the homeless people in the U.S., despite representing just 12% of the country’s overall population. And Newsom has acknowledged that the numbers are likely far greater than official homeless tallies show. Top health officials say that, to contain soaring safety-net spending and help homeless people get healthy, Medi-Cal has no choice but to combine social services with housing.

Statewide, 5% of Medi-Cal patients account for a staggering 44% of the program’s spending, according to state data. And many of the costliest patients lack stable housing: Nearly half of patients experiencing homelessness visited the emergency room four times or more in 2019 and were more likely than other low-income adults to be admitted to the hospital, and a large majority of visits were covered by Medi-Cal, according to the Public Policy Institute of California.

“What we have today doesn’t work,” said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, explaining his argument that housing is a critical component of health care. “Why do we have to wait so long for people to be so sick?”

Stephen Morton moved into his Laguna Woods apartment in Orange County in December 2021. He says his health has improved and that he has been able to drop one of his diabetes medications.(Heidi de Marco / KHN)

The federal government has already approved a massive social experiment in California, known as CalAIM, which is transforming Medi-Cal. Over five years, the initiative is expected to pour $12 billion into new Medi-Cal services delivered outside of traditional health care. In communities across the state, it is already funding services for some low-income patients, including paying rental security deposits for homeless people and those facing eviction; delivering prepared healthy meals for people with diabetes; and helping formerly incarcerated people find jobs.

The transitional rent program would add another service to those already available, though only a sliver of the 15.4 million Medi-Cal enrollees actually receive those new and expensive social services.

Rent payments could begin as soon as 2025 and cost roughly $117 million per year once fully implemented. And while state officials say anyone who is homeless or at risk of becoming homeless would be eligible, not everyone who qualifies will receive new services due to capacity limits. Among those who stand to benefit are nearly 11,000 people already enrolled in Medi-Cal housing services.

“The ongoing conversation is how do we convince the federal government that housing is a health care issue,” said Mari Cantwell, who served as Medi-Cal director from 2015 to 2020. “You have to convince them that you’re going to save money because you’re not going to have as many people showing up at the emergency room and in long-term hospitalizations.”

Health care experiments in California and around the country that funded housing supports have demonstrated early success in reducing costs and making people healthier. But while some programs paid for housing security deposits or participants’ first month of rent, none directly covered rent for an extended period.

“Without that foundational support, we are playing in the margins,” Newsom said.

State health officials argue that paying for six months of rent will be even more successful at reducing health care costs and improving enrollees’ health, but experts say that, to work, the initiative must have strict accountability and be bundled with an array of social services.

Stephen Morton has major health problems, including chronic heart disease, diabetes, and asthma. California wants to tap federal health care funding to cover rent for formerly homeless people. (Heidi de Marco / KHN)

In a precursor to the state’s current initiative, California experimented with a mix of housing assistance programs and social services through its “Whole Person Care” pilot program. Nadereh Pourat, of the UCLA Center for Health Policy Research, evaluated the program for the state concluding that local trials reduced emergency visits and hospitalizations, saving an average of $383 per Medi-Cal beneficiary per year — a meager amount compared with the program’s cost.

Over five years, the state spent $3.6 billion serving about 250,000 patients enrolled in local experiments, Pourat said.

And a randomized control trial in Santa Clara County that provided supportive housing for homeless people showed reductions in psychiatric emergency room visits and improvements in care. “Lives stabilized and we saw a huge uptick in substance use care and mental health care, the things that everybody wants people to use to get healthier,” said Dr. Margot Kushel, director of the University of California-San Francisco’s Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, who worked on the study.

But insurers implementing the broader Medi-Cal initiative say they are skeptical that spending health care money on housing will save the system money. And health care experts say that, while six months of rent can be a bridge while people wait for permanent housing, there’s a bigger obstacle: California’s affordable housing shortage.

“We can design incredible Medicaid policies to alleviate homelessness and pay for all the necessary supportive services, but without the adequate housing, frankly, it’s not going to work,” Kushel said.

Newsom acknowledges that criticism. “The crisis of homelessness will never be solved without first solving the crisis of housing,” he said last week, arguing California should plow more money into housing for homeless people with severe mental health conditions or addiction disorders.

He will ask the legislature to put before voters a 2024 ballot initiative that would infuse California’s mental health system with at least 6,000 new treatment beds and supportive housing units for people struggling with mental health and addiction disorders, many of whom are homeless. The proposed bond measure would generate from $3 billion to $5 billion for psychiatric housing and treatment villages aimed at serving more than 10,000 additional people a year. The initiative also would ask voters to set aside at least $1 billion a year for supportive housing from an existing tax on California millionaires that funds local mental health programs.

“People who are struggling with these issues, especially those who are on the streets or in other vulnerable conditions, will have more resources to get the help they need,” Newsom said.

Stephen Morton lived in shelters and sometimes in his car for almost two years before finding permanent housing. (Heidi de Marco / KHN)

For transitional rent, six months of payments would be available for select high-need residents enrolled in Medi-Cal, particularly those who are homeless or at risk of becoming homeless — and those transitioning from more costly institutions such as mental health crisis centers, jails and prisons, and foster care. Medi-Cal patients at risk of inpatient hospitalization or who frequent the emergency room would also be eligible.

“It’s a pretty big challenge; I’m not going to lie,” said Jacey Cooper, the Medi-Cal director. “But we know that people experiencing homelessness cycle in and out of emergency rooms, so we have a real role to play in both preventing and ending homelessness.”

Public health experts say the problem will continue to explode without creative thinking about how to fund housing in health care, but they warn the state must be wary of potential abuses of the program.

“It has to be designed carefully because, unfortunately, there are always people looking to game the system,” said Dr. Tony Iton, a public health expert who is now a senior vice president at the California Endowment. “Decisions must be made by clinicians — not housing organizations just looking for another source of revenue.”

For Stephen Morton, who lives in the Orange County community of Laguna Woods, the journey from homelessness into permanent housing illustrates the amount of public spending it can take for the effort to pay off.

Morton, 60, bounced between shelters and his car for nearly two years and racked up extraordinary Medi-Cal costs due to prolonged hospitalizations and repeated emergency room trips to treat chronic heart disease, asthma, and diabetes.

Medi-Cal covered Morton’s open-heart surgery and hospital stays, which lasted weeks. He landed temporary housing through a state-sponsored program called Project Roomkey before getting permanent housing through a federal low-income housing voucher — an ongoing benefit that covers all but $50 of his rent.

Since getting his apartment, Morton said, he’s been able to stop taking one diabetes medication and lose weight. He attributes improvements in his blood sugar levels to his housing and the healthy, home-delivered meals he receives via Medi-Cal.

“It’s usually scrambled eggs for breakfast and the fish menu for dinner. I’m shocked it’s so good,” Morton said. “Now I have a microwave and I’m indoors. I’m so grateful and so much healthier.”

Stephen Morton receives weekly deliveries of medically tailored meals as part of a Medi-Cal initiative. Since getting his apartment, Morton says he’s been able to stop taking one diabetes medication and lose weight. (Heidi de Marco / KHN)

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

March 22, 2023

End of Covid Emergency Will Usher in Changes Across the US Health System

The Biden administration’s decision to end the covid-19 public health emergency in May will institute sweeping changes across the health care system that go far beyond many people having to pay more for covid tests.

In response to the pandemic, the federal government in 2020 suspended many of its rules on how care is delivered. That transformed essentially every corner of American health care — from hospitals and nursing homes to public health and treatment for people recovering from addiction.

Now, as the government prepares to reverse some of those steps, here’s a glimpse at ways patients will be affected:

Training Rules for Nursing Home Staff Get Stricter

The end of the emergency means nursing homes will have to meet higher standards for training workers.

Advocates for nursing home residents are eager to see the old, tougher training requirements reinstated, but the industry says that move could worsen staffing shortages plaguing facilities nationwide.

In the early days of the pandemic, to help nursing homes function under the virus’s onslaught, the federal government relaxed training requirements. The Centers for Medicare & Medicaid Services instituted a national policy saying nursing homes needn’t follow regulations requiring nurse aides to undergo at least 75 hours of state-approved training. Normally, a nursing home couldn’t employ aides for more than four months unless they met those requirements.

Last year, CMS decided the relaxed training rules would no longer apply nationwide, but states and facilities could ask for permission to be held to the lower standards. As of March, 17 states had such exemptions, according to CMS — Georgia, Indiana, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, New Jersey, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, and Washington — as did 356 individual nursing homes in Arizona, California, Delaware, Florida, Illinois, Iowa, Kansas, Kentucky, Michigan, Nebraska, New Hampshire, North Carolina, Ohio, Oregon, Virginia, Wisconsin, and Washington, D.C.

Nurse aides often provide the most direct and labor-intensive care for residents, including bathing and other hygiene-related tasks, feeding, monitoring vital signs, and keeping rooms clean. Research has shown that nursing homes with staffing instability maintain a lower quality of care.

Advocates for nursing home residents are pleased the training exceptions will end but fear that the quality of care could nevertheless deteriorate. That’s because CMS has signaled that, after the looser standards expire, some of the hours that nurse aides logged during the pandemic could count toward their 75 hours of required training. On-the-job experience, however, is not necessarily a sound substitute for the training workers missed, advocates argue.

Adequate training of aides is crucial so “they know what they’re doing before they provide care, for their own good as well as for the residents,” said Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy.

The American Health Care Association, the largest nursing home lobbying group, released a December survey finding that roughly 4 in 5 facilities were dealing with moderate to high levels of staff shortages.

Treatment Threatened for People Recovering From Addiction

A looming rollback of broader access to buprenorphine, an important medication for people in recovery from opioid addiction, is alarming patients and doctors.

During the public health emergency, the Drug Enforcement Administration said providers could prescribe certain controlled substances virtually or over the phone without first conducting an in-person medical evaluation. One of those drugs, buprenorphine, is an opioid that can prevent debilitating withdrawal symptoms for people trying to recover from addiction to other opioids. Research has shown using it more than halves the risk of overdose.

Amid a national epidemic of opioid addiction, if the expanded policy for buprenorphine ends, “thousands of people are going to die,” said Ryan Hampton, an activist who is in recovery.

The DEA in late February proposed regulations that would partly roll back the prescribing of controlled substances through telemedicine. A clinician could use telemedicine to order an initial 30-day supply of medications such as buprenorphine, Ambien, Valium, and Xanax, but patients would need an in-person evaluation to get a refill.

For another group of drugs, including Adderall, Ritalin, and oxycodone, the DEA proposal would institute tighter controls. Patients seeking those medications would need to see a doctor in person for an initial prescription.

David Herzberg, a historian of drugs at the University at Buffalo, said the DEA’s approach reflects a fundamental challenge in developing drug policy: meeting the needs of people who rely on a drug that can be abused without making that drug too readily available to others.

The DEA, he added, is “clearly seriously wrestling with this problem.”

Hospitals Return to Normal, Somewhat

During the pandemic, CMS has tried to limit problems that could arise if there weren’t enough health care workers to treat patients — especially before there were covid vaccines when workers were at greater risk of getting sick.

For example, CMS allowed hospitals to make broader use of nurse practitioners and physician assistants when caring for Medicare patients. And new physicians not yet credentialed to work at a particular hospital — for example, because governing bodies lacked time to conduct their reviews — could nonetheless practice there.

Other changes during the public health emergency were meant to shore up hospital capacity. Critical access hospitals, small hospitals located in rural areas, didn’t have to comply with federal rules for Medicare stating they were limited to 25 inpatient beds and patients’ stays could not exceed 96 hours, on average.

Once the emergency ends, those exceptions will disappear.

Hospitals are trying to persuade federal officials to maintain multiple covid-era policies beyond the emergency or work with Congress to change the law.

Surveillance of Infectious Diseases Splinters

The way state and local public health departments monitor the spread of disease will change after the emergency ends, because the Department of Health and Human Services won’t be able to require labs to report covid testing data.

Without a uniform, federal requirement, how states and counties track the spread of the coronavirus will vary. In addition, though hospitals will still provide covid data to the federal government, they may do so less frequently.

Public health departments are still getting their arms around the scope of the changes, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

In some ways, the end of the emergency provides public health officials an opportunity to rethink covid surveillance. Compared with the pandemic’s early days, when at-home tests were unavailable and people relied heavily on labs to determine whether they were infected, testing data from labs now reveals less about how the virus is spreading.

Public health officials don’t think “getting all test results from all lab tests is potentially the right strategy anymore,” Hamilton said. Flu surveillance provides a potential alternative model: For influenza, public health departments seek test results from a sampling of labs.

“We’re still trying to work out what’s the best, consistent strategy. And I don’t think we have that yet,” Hamilton said.

March 22, 2023

A Lot of Thought, Little Action: Proposals About Mental Health Go Unheeded

Thousands of people struggle to access mental health services in Florida. The treatment system is disjointed and complex. Some residents bounce between providers and are prescribed different medications with clinicians unaware of what happened. Jails and prisons have become de facto homes for many who need care.

These problems and more were identified in a scathing report released earlier this year by the Commission on Mental Health and Substance Abuse, a 19-person panel that Florida lawmakers created in 2021 to push for reforms of the state’s patchwork of behavioral health services for uninsured people and low-income families.

What’s most troubling about the group’s findings? They aren’t new.

More than 20 years ago, the Florida Legislature set up a commission with the same name to examine the same issues and publish recommendations on how to improve mental health care in the publicly funded system.

The echoes between the two groups — over two decades apart — are unmistakable. And Florida isn’t the only state struggling with the criminalization of mental illness, a lack of coordination between providers, and insufficient access to treatment.

Last year, the national advocacy group Mental Health America said Florida ranked 46th among the 50 states and the District of Columbia for access to such care. Arizona, Kansas, Georgia, Alabama, and Texas were worse off, according to the nonprofit, which based its rankings on access to insurance, treatment, and special education, along with the cost and quality of insurance and the number of mental health providers.

Conversations about mental health are at the forefront nationwide amid the proliferation of mass shootings, pandemic-related stress, rising suicide rates, and shifting viewpoints on the role of police in handling 911 calls.

“It comes down to how much investment, financially, legislators are willing to put into building a system that works,” said Caren Howard, director of policy and advocacy at Mental Health America, a nonprofit just outside Washington, D.C.

In Florida, the 1999 Commission on Mental Health and Substance Abuse was launched when Jeb Bush was governor. In a 74-page report released in 2001, the group called the state’s treatment system “complex, fragmented, uncoordinated and often ineffective.”

The commission found that jails and prisons were Florida’s “largest mental hospitals” after “deinstitutionalization” began — the 20^th-century movement to shutter state psychiatric facilities and treat people instead through community services.

The report also blasted Florida agencies for not sharing patient data with one another and being unable to track whether those with severe mental illnesses like schizophrenia were truly getting needed help.

“A lot of the things that we’re finding now, they found back then,” said Charlotte County Sheriff Bill Prummell, a member of the latest commission who served as the chairperson for about 18 months.

The similarities raise questions for the group about whether its work will also end up on a shelf, collecting dust, as Florida lawmakers continue to wrestle with the same challenges again and again.

“Are they really going to take us seriously?” Prummell asked.

A man reaching for an item in a bookshelf filled with old books and reports. — A copy of the 2001 report released by Florida’s 1999 Commission on Mental Health and Substance Abuse rests on a shelf in David Shern’s home office.(Ivy Ceballo / Tampa Bay Times)

Dropping the Ball

After hosting public meetings across Florida, the 1999 commission urged a slate of reforms, including expanding jail diversion programs like mental health courts.

But the group’s key recommendation was to set up a “coordinating council” in the governor’s office to lead the system and develop a strategy for care.

That never happened.

David Shern, chairperson of the 1999 group and former dean of the University of South Florida’s Louis de la Parte Florida Mental Health Institute, said he thinks Bush’s office dropped the ball.

The Republican governor, known for his spending cuts, didn’t want to add staff to his office, so the coordinating council was never created, said Shern.

That’s “where the plan really fell apart,” he said.

Instead, lawmakers established a work group in the Department of Children and Families to review how Florida could improve its behavioral health system and submit a report to Bush, among other leaders.

The work group disbanded in 2003. That same year, the legislature created a not-for-profit corporation to oversee the system, but it was dissolved in 2011, according to state business records. When the Tampa Bay Times recently asked for the work group’s report, Laura Walthall, a spokesperson for the Department of Children and Families, said it couldn’t be found. Bush didn’t respond to emailed questions.

Former state Rep. Sandra Murman, however, said that what happened is just a reality of bureaucracy.

“It’s the same with all commissions,” said Murman, a Tampa Republican who was part of the 1999 group. “The life cycle of any big report that comes out is probably about five years.”

Lawmakers leave Tallahassee because of term limits. Agency heads step down. New officials get elected. Priorities shift.

“They come in with their agenda, and you won’t see social services ever at the top,” she said of Florida legislative leaders.

A close-up photo of the Florida mental health commission report released in 2001. — David Shern holds a copy of the report his mental health commission released in 2001. A recent report by a new state commission reached similar conclusions.(Ivy Ceballo / Tampa Bay Times)

But some state lawmakers focused on mental illness in the wake of the 2018 shooting that left 17 students and staff members dead at Marjory Stoneman Douglas High School in Parkland. Amid mounting public demand for more drastic gun control measures, such as an assault weapons ban, the Republican-controlled legislature instead approved more limited restrictions, like Florida’s “red flag” law, along with steps unrelated to gun control, allocating about $400 million for mental health and school safety initiatives.

Before the massacre, Parkland shooter Nikolas Cruz received mental health services through several public and private providers, splitting the future gunman’s medical history, according to a 2019 report from the Marjory Stoneman Douglas High School Public Safety Commission.

“No single health professional or entity had the entire ‘story’ regarding Cruz’s mental health and family issues, due, in part, to an absence of communication between providers and a lack of disclosure by the Cruz family,” the report said.

The vast majority of people with a mental illness are not violent, according to the nonprofit National Council for Mental Wellbeing in Washington, D.C. And they are more likely to be victims of violent crime than perpetrators.

In 2020, a grand jury investigating school safety issues related to the shooting called Florida’s mental health care system “a mess.”

“Deficiencies in funding, leadership and services,” the grand jury said, “tend to turn up everywhere like bad pennies.”

The panel said it didn’t have enough time to conduct a full review of the system and urged state lawmakers to set up a commission to do so.

The latest commission reported that the system remains splintered and suffers from “enormous gaps in treatment.” And there’s still no centralized database on patients.

The group, just like its predecessor over two decades ago, has suggested that Florida create more jail diversion programs and that state agencies share patient data. The commission has pitched new ideas, too, like a pilot program in which one agency manages all public behavioral health funding in a geographic area, including state money and local dollars, so providers can focus more on care and less on complicated billing processes.

“This isn’t going away, and if we don’t address it, it’s going to get worse,” Prummell told a House subcommittee last month.

Solutions to Florida’s problems are not headline grabbers, which makes it tough to generate political support, said Holly Bullard, chief strategy and development officer at the Florida Policy Institute, an Orlando nonprofit.

“Building good government, it can get technical,” she said, “and sometimes it’s hard to communicate the importance of it.”

Will Anything Change?

A photo of a man putting a copy of a report away on his bookshelf. — David Shern with a copy of the report his mental health commission released in 2001.(Ivy Ceballo / Tampa Bay Times)

There’s been some progress in Florida’s mental health care system since 2001, said Jay Reeve, the new chairperson of the latest commission and CEO of Apalachee Center, a behavioral health provider in Tallahassee.

The system is more responsive to regional issues, partly because of state contracts with seven “managing entities” — nonprofits that oversee safety-net services for the uninsured, he said.

There’s also been an increase in initiatives like mobile response teams, which help people in mental health emergencies, and crisis intervention training for police officers, in which they get trained on de-escalation techniques and psychiatric diagnoses so they know when to get residents into treatment instead of arresting them, Reeve said.

The Department of Children and Families used to spend about $500 million a year on community-based behavioral health services such as outpatient treatment, case management, and crisis stabilization units, the 1999 commission reported. Now, its budget for such care is $1.1 billion.

Pockets of innovation exist at the local level, too, as in Palm Beach County, where an initiative called BeWellPBC aims to boost the area’s mental health care workforce, among other things, said Shern, senior associate in the department of mental health at the Johns Hopkins Bloomberg School of Public Health.

But challenges remain.

Nearly 3 million Florida adults have a mental illness, according to Mental Health America. That’s about 17% of the state’s population of those 18 and up. An estimated 225,000 youths experienced at least one major depressive episode in the past year, the nonprofit reported in October.

In 2020, Florida ranked last among states for per capita mental health care funding, the Parkland grand jury said. In 2021, the Miami-Dade County jail system was the largest psychiatric institution in the state, according to the 11th Judicial Circuit.

“As long as you keep things siloed, accountability is easier to dodge,” said Ann Berner, a member of the 2021 commission and CEO of Southeast Florida Behavioral Health Network, a managing entity.

Political will is needed to enact major reforms, Shern said. So is follow-up on the commission’s work, said Murman, who works at Shumaker Advisors Florida, a lobbying firm.

“In this case, it probably is something that has to be revived every five years to really make an impact,” she said.

Rep. Christine Hunschofsky, a Parkland Democrat on the 2021 commission, said there’s bipartisan support to improve the system.

But during the current legislative session, the Tampa Bay Times on March 13 could find only one House bill and a matching Senate bill based on the commission’s 35-page interim report: a proposal to study Medicaid expansion for some young adults age 26 and under. (Republican leaders in Florida have refused to expand the federal-state health care program under the Affordable Care Act, which became law in 2010.)

Hunschofsky said she thinks the legislature will take more action once the commission releases its final report, which is due by Sept. 1.

Republican Gov. Ron DeSantis’ office referred questions to the Department of Children and Families, where officials didn’t answer them.

Senate President Kathleen Passidomo didn’t respond to a voicemail and interview requests made through a spokesperson. Nor could House Speaker Paul Renner be reached for comment.

After more than 20 years, Shern is frustrated.

“It’s time to move on these issues,” he said. “We’ve spent literally decades thinking about them, talking about them.”

A photo of a man posing for a portrait in his office. — David Shern in his home office.(Ivy Ceballo / Tampa Bay Times)

This article was produced in partnership with the Tampa Bay Times.

March 21, 2023

Mental Health Care by Video Fills Gaps in Rural Nursing Homes

KNOXVILLE, Iowa ― Bette Helm was glad to have someone to talk with about her insomnia.

Helm lives in a nursing home in this central Iowa town of about 7,500 people, where mental health services are sparse. On a recent morning, she had an appointment with a psychiatric nurse practitioner about 800 miles away in Austin, Texas. They spoke via video, with Helm using an iPad she held on her lap while sitting in her bed.

Video visits are an increasingly common way for residents of small-town nursing homes to receive mental health care. Patients don’t have to travel to a clinic. They don’t even have to get cleaned up and leave their bedrooms, which can be daunting for people with depression or anxiety. Online care providers face fewer appointment cancellations, and they often can work from home. While use of some other telehealth services may dwindle as the covid-19 pandemic winds down, providers predict demand for remote mental health services will continue to increase in rural nursing homes.

“Are you anxious when you try to fall asleep? Is your mind racing?” asked the nurse practitioner, Ayesha Macon.

“Yeah, that’s sort of my time to think,” Helm said. Her thoughts can keep her up past 3 a.m., she said.

They discussed the anxiety Helm sometimes feels during the day and her routine of watching the TV news at 10 p.m. Macon suggested the news might wind Helm up, and she wondered if the 71-year-old patient could ease stress by skipping the news before going to bed.

“No,” Helm said. “I find it interesting. I want to know what’s going on in the world. I’ve always been a bit of a newshound.”

Macon smiled and said she understood. So they talked about other approaches, including using online meditation programs and spending quiet time reading the dozens of novels Helm keeps stacked in her room. “If I couldn’t read, I think I would go absolutely bananas,” she told Macon, who agreed it was a good habit.

Telemedicine visits became much more common throughout the American health care system during the pandemic, as guidelines on “social distancing” curtailed in-person appointments and insurers eased restrictions on what they would cover. The number of telehealth visits paid for by Medicare jumped tenfold in the last nine months of 2020 compared with the same period a year before.

Supporters of online treatment say it’s a good match for mental health care, especially in settings where in-person services have been hard to arrange. They cite small-town nursing homes as prime examples. The company that arranged Helm’s recent appointment, Encounter Telehealth, serves more than 200 nursing homes and assisted living centers, mostly in the Midwest. About 95% of those facilities are in rural areas, said Jen Amis, president of the company, which is based in Omaha, Nebraska.

Encounter Telehealth uses about 20 mental health professionals, many of whom are psychiatric nurse practitioners living in cities. The practitioners read the patients’ electronic medical records through a secure computer system, and they review symptoms and medications with nursing home staff members before each appointment. They complete up to 2,000 visits a month.

It’s important for seniors to have expert support as they face stress and uncertainty in aging, Amis said. “We’re all going to be there at some point,” she said. “Don’t you want that last chapter to be peaceful?”

The company saw demand for its services surge in care facilities when the pandemic hit. Nursing homes were closed to visitors for months at a time while the coronavirus caused thousands of illnesses and deaths among residents and employees. The stress could be overwhelming for everyone involved. “Oh, my gosh, the isolation and fear,” Amis said.

Amis said several developments have made her company’s services possible. Electronic medical records and video systems are crucial. Also, she said, many states have given more independent authority to nurse practitioners and other nonphysicians, and it has become easier to bill public and private insurance plans for mental health treatment.

The federal government could tighten rules for some kinds of telehealth care as the pandemic wanes. But Medicare paid for many remote mental health visits to rural areas before covid, and Amis expects the support to continue.

Jonathan Neufeld, program director of the Great Plains Telehealth Resource and Assistance Center at the University of Minnesota, said in-person mental health care can be hard to arrange in rural care facilities.

“You’ve got a double or even triple whammy going right now,” said Neufeld, a psychologist whose center is supported by federal grants.

He noted the number of mental health professionals nationally has been insufficient for many years, even before the pandemic. And all kinds of rural employers, including nursing homes, face critical staffing shortages.

Neufeld said telehealth visits can be a challenge for some care-facility residents, including those with dementia, who might not understand how a video feed works. But he said it also can be difficult to treat people with dementia in person. Either way, a staff member or relative needs to accompany them during appointments and the mental health professional generally consults with facility staff about a patient’s treatment.

Before telemedicine was available, more residents of rural nursing homes needed to be driven to a clinic in another town to see a mental health professional. That could eat up hours of staff time and add stress to the patients’ lives.

Seleta Stewart, a certified nursing assistant at the Accura HealthCare nursing home where Helm lives, said the facility’s need for the telehealth service is increasing, partly because the facility is home to several younger residents with mental illnesses. In the past, she said, many such Iowans would have been served by specialized facilities, such as two state mental hospitals that closed in 2015. But more now live in nursing homes.

“Iowa is just not a great state for mental health,” Stewart said.

A photo of a nursing home worker speaking to a mental health worker via video call. — Before visiting with patients in their rooms, psychiatric nurse practitioner Ayesha Macon, on video screen, consults with Shaina Flesher (right), a certified nursing assistant at the Accura HealthCare nursing home in Knoxville, Iowa. The two discuss how residents of the nursing home have been faring and what medications they’ve been taking.(Tony Leys / KHN)

Neufeld said that, even with telemedicine’s efficiencies, staffing can be a challenge for companies providing the service in nursing homes. Many mental health professionals already have more patients than they can handle, and they might not have time to pitch in online. He added that Medicare, which insures most seniors, pays lower rates than private insurers or patients paying on their own.

Amis, Encounter Telehealth’s president, said Medicare pays about $172 for an initial appointment and about $107 for a follow-up appointment; care providers collect roughly 30% to 75% more from patients who use private insurance or pay their own bills, she said. She added that nursing homes pay a fee to Encounter for the convenience of having mental health professionals visit by video.

Several patients and care providers said the shift to video appointments is usually smooth, despite seniors’ reputation for being uncomfortable with new technology.

Dr. Terry Rabinowitz, a psychiatrist and professor at the University of Vermont, has been providing telemedicine services to a rural nursing home in upstate New York since 2002. He said many patients quickly adjust to video visits, even if it’s not their initial preference.

“I think most people, if they had their druthers, would rather see me in person,” he said. “And if I had my druthers, I’d rather see them in person.” Online visits can have special challenges, including for patients who don’t hear or see well, he said. But those complications can be addressed.

Nancy Bennett, another resident of Helm’s Iowa nursing home, can attest to the benefits. Bennett had a video appointment with Macon on a recent morning. She told the nurse practitioner she’d been feeling stressed. “I’m 72, I’m in a nursing home, I’ve got no family around, so yeah, I’m a little depressed,” she said. “I do get sad sometimes.”

“That’s normal,” Macon assured her.

Bennett said she dislikes taking a lot of pills. Macon said she could taper some of Bennett’s medication.

In an interview afterward, Bennett said she’d gone to a clinic for mental health care in the past. That was before physical issues forced her into the nursing home, where she spends much of her time sitting in a blue recliner in her room.

If she’d had to get dressed and travel for her appointment with Macon, she said, she probably would have canceled. “There are days when I don’t want to be bothered,” she said.

But on this day, the mental health professional came to her on an iPad ― and helped Bennett feel a little better.

March 21, 2023

Some Roadblocks to Lifesaving Addiction Treatment Are Gone. Now What?

For two decades — as opioid overdose deaths rose steadily — the federal government limited access to buprenorphine, a medication that addiction experts consider the gold standard for treating patients with opioid use disorder. Study after study shows it helps people continue addiction treatment while reducing the risk of overdose and death.

Clinicians who wanted to prescribe the medicine had to complete an eight-hour training. They could treat only a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration registration number starting with X, a designation many doctors say made them a target for drug-enforcement audits.

“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘Boy, this is dangerous stuff,’” said Dr. Bobby Mukkamala, who chairs an American Medical Association task force addressing substance use disorder.

“The science doesn’t support that but the rigamarole suggested that.”

That rigamarole is mostly gone. Congress eliminated what became known as the “X-waiver” in legislation President Joe Biden signed late last year. Now begins what some addiction experts are calling a “truth serum moment.”

Were the X-waiver and the burdens that came with it the real reason only about 7% of clinicians in the U.S. were cleared to prescribe buprenorphine? Or were they an excuse that masked hesitation about treating addiction, if not outright disdain for these patients?

There’s great optimism among some leaders in the field that getting rid of the X-waiver will expand access to buprenorphine and reduce overdoses. One study from 2021 shows taking buprenorphine or methadone, another opioid agonist treatment, reduces the mortality risk for people with opioid dependence by 50%. The medication is an opioid that produces much weaker effects than heroin or fentanyl and reduces cravings for those deadlier drugs.

The nation’s drug czar, Dr. Rahul Gupta, said getting rid of the X-waiver would ultimately prevent millions of deaths.

“The impact of this will be felt for years to come,” Gupta said. “It is a true historic change that, frankly, I could only dream of being possible.”

Gupta and others envision obstetricians prescribing buprenorphine to their pregnant patients, infectious disease doctors adding it to their medical toolbox, and lots more patients starting buprenorphine when they come to emergency rooms, primary care clinics, and rehabilitation facilities.

We are “transforming the way we think to make every moment an opportunity to start this treatment and save someone’s life,” said Dr. Sarah Wakeman, the medical director for substance use disorder at Mass General Brigham in Boston.

Wakeman said clinicians she has been contacting for the past decade are finally willing to consider treating patients with buprenorphine. Still, she knows stigma and discrimination could undermine efforts to help those who aren’t being served. In 2021, a national survey showed just 22% of people with opioid use disorder received medications such as buprenorphine and methadone.

The test of whether clinicians will step up and if prescribing will become more widespread is underway in hospitals and clinics across the country as patients struggling with addiction queue up for treatment. A woman named Kim, 65, is among them.

Kim’s recent visit to the Greater New Bedford Community Health Center in southern Massachusetts began in an exam room with Jamie Simmons, a registered nurse who runs the center’s addiction treatment program but doesn’t have prescribing powers. KHN agreed to use only Kim’s first name to limit potential discrimination linked to her drug use.

Kim told Simmons that buprenorphine had helped her stay off heroin and avoid an overdose for nearly 20 years. Kim takes a medication called Suboxone, a combination of buprenorphine and naloxone, which comes in the form of thin, filmlike strips she dissolves under her tongue.

“It’s the best thing they could have ever come out with,” Kim said. “I don’t think I ever even had a desire to use heroin since I’ve been taking them.”

Buprenorphine can produce mild euphoria and slow breathing but there’s a ceiling on the effects. Patients like Kim may develop a tolerance and not experience any effects.

“I don’t get high on Suboxones,” Kim said. “They just keep me normal.”

Still, many clinicians have been hesitant to use buprenorphine — known as a partial opioid agonist — to treat an addiction to more deadly forms of the drug.

Kim’s primary care doctor at the health center never applied for an X-waiver. So for years Kim bounced from one treatment program to another, seeking a prescription. During lapses in her access to buprenorphine, the cravings returned — an especially scary prospect after the powerful opioid fentanyl largely replaced heroin on the streets of Massachusetts, where Kim lives.

“I’ve seen so many people fall out in the last month,” Kim said, using a slang term for overdosing. “That stuff is so strong that within a couple minutes, boom.”

Because fentanyl can kill so quickly, the benefits of taking buprenorphine and other medications to treat opioid use disorder have increased as deaths linked to even stronger types of fentanyl rise.

Buprenorphine is present in a small percentage of overdose deaths nationwide, 2.6%. Of those, 93% involved a mix of one or more other drugs, often benzodiazepines. Fentanyl is in 94% of overdose deaths in Massachusetts.

“Bottom line is, fentanyl kills people, buprenorphine doesn’t,” Simmons said.

That reality added urgency to Kim’s health center visit because Kim took her last Suboxone before arriving; her latest prescription had run out.

Cravings for heroin could have returned in about a day if she didn’t get more Suboxone. Simmons confirmed the dose and told Kim that her primary care doctor might be willing to renew the prescription now that the X-waiver is not required. But Dr. Than Win had some concerns after reviewing Kim’s most recent urine test. It showed traces of cocaine, fentanyl, marijuana, and Xanax, and Win said she was worried about how the street drugs might interact with buprenorphine.

“I don’t want my patients to die from an overdose,” Win said. “But I’m not comfortable with the fentanyl and a lot of narcotics in the system.”

Kim was adamant that she did not intentionally ingest fentanyl, saying it might have been in the cocaine she said her roommate shares occasionally. Kim said she takes the Xanax to sleep. Her drug use presents complications that many primary care doctors don’t have experience managing. Some clinicians are apprehensive about using an opioid to treat an addiction to opioids, despite compelling evidence that doing so can save patients’ lives.

Win was worried about writing her first prescription for Suboxone. But she agreed to help Kim stay on the medication.

“I wanted to start with someone a little bit easier,” Win said. “It’s hard for me; that’s the reality and truth.”

About half of the providers at the Greater New Bedford health center had an X-waiver when it was still required. Attributing some of the resistance to having the waiver to stigma or misunderstanding about addiction, Simmons urged doctors to treat addiction as they would any other disease.

“You wouldn’t not treat a diabetic; you wouldn’t not treat a patient who is hypertensive,” Simmons said. “People can’t control that they formed an addiction to an opiate, alcohol, or a benzo.”

Searching for Solutions to Soften Stigma

Although the restrictions on buprenorphine prescribing are no longer in place, Mukkamala said the perception created by the X-waiver lingers.

“That legacy of elevating this to a level of scrutiny and caution —that needs to be sort of walked back,” Mukkamala said. “That’s going to come from education.”

Mukkamala sees promise in the next generation of doctors, nurse practitioners, and physician assistants coming out of schools that have added addiction training. The AMA and the American Society of Addiction Medicine have online resources for clinicians who want to learn on their own.

Some of these resources may help fulfill a new training requirement for clinicians who prescribe buprenorphine and other controlled narcotics. It will take effect in June. The DEA has not issued details about the training.

But training alone may not shift behavior, as Rhode Island’s experience shows.

The number of Rhode Island practitioners approved to prescribe buprenorphine increased roughly threefold from 2016 to 2022 after the state said physicians in training should obtain an X-waiver. Still, having the option to prescribe buprenorphine “didn’t open the floodgates” for patients in need of treatment, said Dr. Jody Rich, an addiction specialist who teaches at Brown University. From 2016 to 2022, when the number of qualified prescribers increased, the number of patients taking buprenorphine also increased, but by a much smaller percentage.

“It all comes back to stigma,” Rich said.

He said long-standing resistance among some providers to treating addiction is shifting as younger people enter medicine. But tackling the opioid crisis can’t wait for a generational change, he said. To expand buprenorphine access now, states could use pharmacists, partnered with doctors, to help manage the care of more patients with opioid use disorder, Rich’s research shows.

Wakeman, at Mass General Brigham, said it might be time to hold clinicians who don’t provide addiction care accountable through quality measures tied to payments.

“We’re expected to care for patients with diabetes or to care for patients with heart attack in a certain way and the same should be true for patients with an opioid use disorder,” Wakeman said.

One quality measure to track could be how often prescribers start and continue buprenorphine treatment. Wakeman said it would help also if insurers reimbursed clinics for the cost of staff who aren’t traditional clinicians but are critical in addiction care, like recovery coaches and case managers.

Will Ending the X-Waiver Close Racial Gaps?

Wakeman and others are paying especially close attention to whether eliminating the X-waiver helps narrow racial gaps in buprenorphine treatment. The medication is much more commonly prescribed to white patients with private insurance or who can pay cash. But there are also stark differences by race at some health centers where most patients are on Medicaid and would seem to have equal access to the addiction treatment.

At the New Bedford health center, Black patients represent 15% of all patients but only 6% of those taking buprenorphine. For Hispanics, it is 30% to 23%. Most of the health center patients prescribed buprenorphine, 61%, are white, though white patients make up just 36% of patients overall.

Dr. Helena Hansen, who co-authored a book on race in the opioid epidemic, said access to buprenorphine doesn’t guarantee that patients will benefit from it.

“People are not able to stay on a lifesaving medication unless the immense instability in housing, employment, social supports — the very fabric of their communities — is addressed,” Hansen said. “That’s where we fall incredibly short in the United States.”

Hansen said expanding access to buprenorphine has helped reduce overdose deaths dramatically among all drug users in France, including those with low incomes and immigrants. There, patients with opioid use disorder are seen in their communities and offered a wide range of social services.

“Removing the X-waiver,” Hansen said, “is not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do much more.”

This article is part of a partnership that includes WBUR, NPR, and KHN.

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