Kaiser Health News
Health Care Workers Push for Their Own Confidential Mental Health Treatment
Katheryn Houghton
Thu, 22 Feb 2024 10:00:00 +0000
States are redefining when medical professionals can get mental health treatment without risking notifying the boards that regulate their licenses.
Too often, health care workers wait to seek counseling or addiction treatment, causing their work and patient care to suffer, said Jean Branscum, CEO of the Montana Medical Association, an industry group representing doctors.
“They’ve invested so much time in their career,” Branscum said. “To have anything jeopardize that is a big worry on their mind.”
Montana, like other states, has a recovery program for health professionals who have a substance use disorder or mental illness. However, medical associations say such programs often come with invasive monitoring, even for voluntary care. And gray areas about when a mental illness should become public breeds fear that seeking care jeopardizes a medical career.
Montana is among the states looking to boost confidential care for health professionals as long as they’re not deemed a danger to themselves or patients. In recent years, at least a dozen states have considered or created confidential wellness programs to offer clinicians help early on for career burnout or mental health issues. States have also reworked medical licensing questions to avoid scrutiny for providers who need mental health treatment. The changes are modeled after Virginia legislation from 2020.
During a legislative committee meeting last month, advocates for Montana medical professionals asked state lawmakers to follow Virginia’s lead. They say the goal is twofold: to get clinicians treatment before patients are at risk and to curtail the workforce burnout that’s partly fueled by untreated stress.
Montana’s existing medical monitoring program, the Montana Recovery Program, is run by the global company Maximus. Montana’s professional advocates had backed another nonprofit to run Montana’s program, which didn’t win the state contract.
The Montana Recovery Program declined a request for an interview, instead referring KFF Health News to the Montana Department of Labor & Industry, which oversees the state’s medical licensing boards. Department staffers didn’t comment by deadline.
In a Medscape survey released this year, 20% of physicians said they felt depressed, with job burnout as a leading factor. The majority said confiding in other doctors wasn’t practical. Some said they might not tell anyone about their depression out of fear people would doubt their abilities, or that their employer or medical board could find out.
Health professionals are leaving their jobs. They’re retiring early, reducing work hours, or switching careers. That further dwindles patients’ care options when there already aren’t enough providers to go around. The federal government estimates 74 million people live in an area without enough primary care services due to a workforce shortage.
Aiming to ensure patient safety, state medical boards can suspend or revoke clinicians’ rights to practice medicine if substance use or psychological disorders impair their work. Those cases are rare. One study found roughly 4,400 actions against the licenses of U.S. physicians for either substance use or psychological impairment from 2004 to 2020.
Nonetheless, workforce advocates say disclosure requirements cause some health professionals to dodge questions about mental health histories on licensing and insurance forms or forgo care altogether. They’re worried divulging any weakness will signal they shouldn’t practice medicine.
The mental health questions health workers are asked vary by state and profession. For example, nurses in Montana renewing their license are asked if they have any psychological condition or substance use that limited their ability to practice “with reasonable skill and safety” in the previous six months. Along with being asked about substance use on the job, doctors are required to say whether they’ve experienced a mental condition that “might adversely affect any aspect of your ability to perform.”
“When I see that question on my renewal, do I have to report that I was depressed because I was going through a really tough divorce?” Branscum cited as an example of workers’ uncertainty. “You know, my life is turned upside down now. Am I obligated to report that?”
A “yes” wouldn’t immediately result in licensing problems. Those who do report mental health troubles would be flagged by state workers as a potential concern. They could end up before the board’s same screening panel that recommends whether to revoke a license, or be referred to long-term monitoring with regular screening.
Additionally, health professionals are required to report when other clinicians show unprofessionalism or have potential issues that affect performance. Branscum said medical professionals worry that what they say in a counseling session could be flagged for licensing boards, or that a co-worker may make a report if they seem depressed at work.
Bob Sise, a Montana addiction psychiatrist and co-founder of the nonprofit 406 Recovery, told state lawmakers that job stressors are playing into workers’ mental health challenges, such as long shifts and heavy patient loads. And with the rising cost of health care, physicians feel they’re sacrificing their commitment to healing as they routinely substitute optimal treatment for lesser care that patients can afford.
Sise said his practice now has roughly 20 health professionals as patients.
“They were able to access care before it was too late,” Sise said. “But they’re the exception.”
In Virginia, doctors, nurses, physician assistants, pharmacists, and students can join the state’s SafeHaven program. Melina Davis, CEO of the Medical Society of Virginia, said the service offers counseling and peer coaching with staffers available to answer a call 24/7.
“If you only have a moment at 2 a.m., or that’s when you had the chance to first process the death of a patient, then you can talk to somebody,” Davis said.
Those in the program are assured that those conversations are privileged and can’t be used in lawsuits. This year, the state is considering adding medical diagnoses under the program’s confidential protections.
States that have followed suit have slight variations, but most create a “safe haven” with two types of wellness and reporting systems. Those who seek out care before they’re impaired at work have broad privacy protections. The other defines a disciplinary track and monitoring system for those who pose a risk to themselves or others. Indiana and South Dakota followed Virginia’s lead in 2021.
States are also narrowing the time frame that licensing boards can ask about mental illness history. The American Medical Association has encouraged states to require health care workers to disclose current physical or mental health conditions, not past diagnoses.
Last year, Georgia updated its license renewal form to ask doctors if any current condition “for which you are not being appropriately treated” affects their ability to practice medicine. That update replaces a request for seven years of mental health history.
Even outside the “safe haven” framework, some states are grappling with how to grant doctors privacy while guaranteeing patient safety.
The Medical Board of California is creating a program to treat and monitor doctors with alcohol and drug illnesses. But patients’ advocates have argued too much privacy, even for voluntary treatment, could risk consumers’ well-being. They told the state medical board that patients have a right to know if their doctor has an addiction.
Davis said states should debate how to balance physicians’ privacy and patients’ safety.
“We in medical professions are supposed to be saving lives,” she said. “Where’s the line where that starts to fall off, where their personal situation could affect that? And how does the system know?”
According to the Montana Recovery Program website, it’s not a program of discipline but instead one “of support, monitoring, and accountability.” Participants may self-refer to the program or be referred by their licensing board.
Branscum, with the Montana Medical Association, said the state’s monitoring program is needed for cases in which an illness impairs a clinician’s work. But she wants that form of treatment to become the exception.
Vicky Byrd, CEO of the Montana Nurses Association, said nurses don’t tend to join the program until they’re forced to in order to keep their license. That leaves many nurses struggling in silence until untreated illness shows up in their work, she said.
“Let’s get them taken care of before it has to go on their license,” Byrd said.
Because after that point, she said, it’s hard to recover.
——————————
By: Katheryn Houghton
Title: Health Care Workers Push for Their Own Confidential Mental Health Treatment
Sourced From: kffhealthnews.org/news/article/confidential-mental-health-treatment-for-health-care-providers/
Published Date: Thu, 22 Feb 2024 10:00:00 +0000
Kaiser Health News
Harris’ California Health Care Battles Signal Fights Ahead for Hospitals if She Wins
Bernard J. Wolfson and Phil Galewitz, KFF Health News
Mon, 05 Aug 2024 09:00:00 +0000
When Kamala Harris was California’s top prosecutor, she was concerned that mergers among hospitals, physician groups, and health insurers could thwart competition and lead to higher prices for patients. If she wins the presidency in November, she’ll have a wide range of options to blunt monopolistic behavior nationwide.
The Democratic vice president could influence the Federal Trade Commission and instruct the departments of Justice and Health and Human Services to prioritize enforcement of antitrust laws and channel resources accordingly. Already, the Biden administration has taken an aggressive stance against mergers and acquisitions. In his first year in office, President Joe Biden issued an executive order intended to intensify antitrust enforcement across multiple industries, including health care.
Under Biden, the FTC and DOJ have fought more mergers than they have in decades, often targeting health care deals.
“What Harris could do is set the tone that she is going to continue this laser focus on competition and health care prices,” said Katie Gudiksen, a senior health policy researcher at University of California College of the Law, San Francisco.
The Harris campaign didn’t respond to a request for comment.
For decades, the health industry has undergone consolidation despite government efforts to maintain competition. When health systems expand, adding hospitals and doctor practices to their portfolios, they often gain a large enough share of regional health care resources to command higher prices from insurers. That results in higher premiums and other health care costs for consumers and employers, according to numerous studies.
Health insurers have also consolidated in recent decades, leaving only a handful controlling most markets.
Health care analysts say it’s possible for Harris to slow the momentum of consolidation by blocking future mergers that could lead to higher prices and lower-quality care. But many of them agree the consolidation that has already taken place is an inescapable feature of the U.S. health care landscape.
“It’s hard to unscramble the eggs,” said Bob Town, an economics professor at the University of Texas.
There were nearly 1,600 hospital mergers in the U.S. from 1998 to 2017 and 428 hospital and health system mergers from 2018 to 2023, according to a KFF study. The percentage of community hospitals that belong to a larger health system rose from 53 in 2005 to 68 in 2022. And in another sign of market concentration, as of January, well over three-quarters of the nation’s physicians were employed by hospitals or corporations, according to a report produced by Avalere Health.
Despite former President Donald Trump’s hostility to regulation as a candidate, his administration was active on antitrust efforts — though it did allow one of the largest health care mergers in U.S. history, between drugstore chain CVS Health and the insurer Aetna. Overall, Trump’s Justice Department was more aggressive on mergers than past Republican administrations.
Harris, as California’s attorney general from 2011 to 2017, jump-started health care investigations and enforcement.
“She pushed back against anticompetitive pricing,” said Rob Bonta, California’s current attorney general, who is a Democrat.
One of Harris’ most impactful decisions was a 2012 investigation into whether consolidation among hospitals and physician practices gave health systems the clout to demand higher prices. That probe bore fruit six years later after Harris’ successor, Xavier Becerra, filed a landmark lawsuit against Sutter Health, the giant Northern California hospital operator, for anticompetitive behavior. Sutter settled with the state for $575 million.
In 2014, Harris was among 16 state attorneys general who joined the FTC in a lawsuit to dismantle a merger between one of Idaho’s largest hospital chains and its biggest physician group. In 2016, Harris joined the U.S. Department of Justice and 11 other states in a successful lawsuit to block a proposed $48.3 billion merger between two of the nation’s largest health insurers, Cigna and Anthem.
Attempts to give the state attorney general the power to nix or impose conditions on a wide range of health care mergers have been fiercely, and successfully, opposed by California’s hospital industry. Most recently, the hospital industry persuaded state lawmakers to exempt for-profit hospitals from pending legislation that would subject private equity-backed health care transactions to review by the attorney general.
A spokesperson for the California Hospital Association declined to comment.
As attorney general of California, Harris’ work was eased by the state’s deep blue political hue. Were she to be elected president, she could face a less hospitable political environment, especially if Republicans control one or both houses of Congress. In addition, she could face opposition from powerful health care lobbyists.
Though it often gets a bad rap, consolidation in health care also confers benefits. Many doctors choose to join large organizations because it relieves them of the administrative headaches and financial burdens of running their own practices. And being absorbed into a large health system can be a lifeline for financially troubled hospitals.
Still, a major reason health systems choose to expand through acquisition is to accumulate market clout so they can match consolidation among insurers and bargain with them for higher payments. It’s an understandable reaction to the financial pressures hospitals are under, said James Robinson, a professor of health economics at the University of California-Berkeley.
Robinson noted that hospitals are required to treat anyone who shows up at the emergency room, including uninsured people. Many hospitals have a large number of patients on Medicaid, which pays poorly. And in California, they face a series of regulatory requirements, including seismic retrofitting and nurse staffing minimums, that are expensive. “How are they going to pay for that?” Robinson said.
At the federal level, any effort to blunt anticompetitive mergers would depend in part on how aggressive the FTC is in pursuing the most egregious cases. FTC Chair Lina Khan has made the FTC more proactive in this regard.
Last year, the FTC and DOJ jointly issued new merger guidelines, which suggested the federal government would scrutinize deals more closely and take a broader view of which ones violate antitrust laws. In September, the FTC filed a lawsuit against an anesthesiology group and its private equity backer, alleging they had engaged in anticompetitive practices in Texas to drive up prices.
In January, the agency sued to stop a $320 million hospital acquisition in North Carolina.
Still, many transactions don’t come to the attention of the FTC because their value is below its $119.5 million reporting threshold. And even if it heard about more deals, “it is very underresourced and needing to be very selective in which mergers they challenge,” said Paul Ginsburg, a professor of the practice of health policy at the University of Southern California’s Sol Price School of Public Policy.
Khan’s term ends in September 2024, and Harris, if elected, could try to reappoint her, though her ability to do so may depend on which party controls the Senate.
Harris could also promote regulations that discourage monopolistic behaviors such as all-or-nothing contracting, in which large health systems refuse to do business with insurance companies unless they agree to include all their facilities in their networks, whether needed or not. That behavior was one of the core allegations in the Sutter case.
She could also seek policies at the Department of Health and Human Services, which runs Medicare and Medicaid, that encourage competition.
Bonta, California’s current attorney general, said that, while there are bad mergers, there are also good ones. “We approve them all the time,” he said. “And we approve them with conditions that address cost and that address access and that address quality.”
He expects Harris to bring similar concerns to the presidency if she wins.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.Â
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By: Bernard J. Wolfson and Phil Galewitz, KFF Health News
Title: Harris’ California Health Care Battles Signal Fights Ahead for Hospitals if She Wins
Sourced From: kffhealthnews.org/news/article/kamala-harris-california-hospitals-health-care-antitrust-ftc/
Published Date: Mon, 05 Aug 2024 09:00:00 +0000
Kaiser Health News
Urgent Care or ER? With ‘One-Stop Shop,’ Hospitals Offer Both Under Same Roof
Phil Galewitz, KFF Health News
Fri, 02 Aug 2024 09:00:00 +0000
JACKSONVILLE, Fla. — Facing an ultracompetitive market in one of the nation’s fastest-growing cities, UF Health is trying a new way to attract patients: a combination emergency room and urgent care center.
In the past year and a half, UF Health and a private equity-backed company, Intuitive Health, have opened three centers that offer both types of care 24/7 so patients don’t have to decide which facility they need.
Instead, doctors there decide whether it’s urgent or emergency care —the health system bills accordingly — and inform the patient of their decision at the time of the service.
“Most of the time you do not realize where you should go — to an urgent care or an ER — and that triage decision you make can have dramatic economic repercussions,” said Steven Wylie, associate vice president for planning and business development at UF Health Jacksonville. About 70% of patients at its facilities are billed at urgent care rates, Wylie said.
Emergency care is almost always more expensive than urgent care. For patients who might otherwise show up at the ER with an urgent care-level problem — a small cut that requires stitches or an infection treatable with antibiotics — the savings could be hundreds or thousands of dollars.
While no research has been conducted on this new hybrid model, consumer advocates worry hospitals are more likely to route patients to costlier ER-level care whenever possible.
For instance, some services that trigger higher-priced, ER-level care at UF Health’s facilities — such as blood work and ultrasounds — can be obtained at some urgent care centers.
“That sounds crazy, that a blood test can trigger an ER fee, which can cost thousands of dollars,” said Cynthia Fisher, founder and chair of PatientRightsAdvocate.org, a patient advocacy organization.
For UF Health, the hybrid centers can increase profits because they help attract patients. Those patient visits can lead to more revenue through diagnostic testing and referrals for specialists or inpatient care.
Offering less expensive urgent care around-the-clock, the hybrid facilities stand out in an industry known for its aggressive billing practices.
On a recent visit to one of UF Health’s facilities about 15 miles southeast of downtown, several patients said in interviews that they sought a short wait for care. None had sat in the waiting room more than five minutes.
“Sometimes urgent care sends you to the ER, so here you can get everything,” said Andrea Cruz, 24, who was pregnant and came in for shortness of breath. Cruz said she was being treated as an ER patient because she needed blood tests and monitoring.
“It’s good to have a place like this that can treat you no matter what,” said Penny Wilding, 91, who said she has no regular physician and was being evaluated for a likely urinary tract infection.
UF Health is one of about a dozen health systems in 10 states partnering with Intuitive Health to set up and run hybrid ER-urgent care facilities. More are in the works; VHC Health, a large hospital in Arlington, Virginia, plans to start building one this year.
Intuitive Health was established in 2008 by three emergency physicians. For several years the company ran independent combination ER-urgent care centers in Texas.
Then Altamont Capital Partners, a multibillion-dollar private equity firm based in Palo Alto, California, bought a majority stake in Intuitive in 2014.
Soon after, the company began partnering with hospitals to open facilities in states including Arizona, Indiana, Kentucky, and Delaware. Under their agreements, the hospitals handle medical staff and billing while Intuitive manages administrative functions — including initial efforts to collect payment, including checking insurance and taking copays — and nonclinical staff, said Thom Herrmann, CEO of Intuitive Health.
Herrmann said hospitals have become more interested in the concept as Medicare and other insurers pay for value instead of just a fee for each service. That means hospitals have an incentive to find ways to treat patients for less.
And Intuitive has a strong incentive to partner with hospitals, said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University: Facilities licensed as freestanding emergency rooms — as Intuitive’s are — must be affiliated with hospitals to be covered by Medicare.
At the combo facilities, emergency room specialists determine whether to bill for higher-priced ER or lower-priced urgent care after patients undergo a medical screening. They compare the care needed against a list of criteria that trigger emergency-level care and bills, such as the patient requiring IV fluids or cardiac monitoring.
Inside its combo facilities, UF posts a sign listing some of the urgent care services it offers, including treatment for ear infections, sprains, and minor wounds. When its doctors determine ER-level care is necessary, UF requires patients to sign a form acknowledging they will be billed for an ER visit.
Patients who opt out of ER care at that time are charged a triage fee. UF would not disclose the amount of the fee, saying it varies.
UF officials say patients pay only for the level of care they need. Its centers accept most insurance plans, including Medicare, which covers people older than 65 and those with disabilities, and Medicaid, the program for low-income people.
But there are important caveats, said Fisher, the patient advocate.
Patients who pay cash for urgent care at UF’s hybrid centers are charged an “all-inclusive” $250 fee, whether they need an X-ray or a rapid strep test, to name two such services, or both.
But if they use insurance, patients may have higher cost sharing if their health plan is charged more than it would pay for stand-alone urgent care, she said.
Also, federal surprise billing protections that shield patients in an ER don’t extend to urgent care centers, Fisher said.
Herrmann said Intuitive’s facilities charge commercial insurers for urgent care the same as if they provided only urgent care. But Medicare may pay more.
While urgent care has long been intended for minor injuries and illnesses and ERs are supposed to be for life– or health-threatening conditions, the two models have melded in recent years. Urgent care clinics have increased the scope of injuries and conditions they can treat, while hospitals have taken to advertising ER wait times on highway billboards to attract patients.
Intuitive is credited with pioneering hybrid ER-urgent care, though its facilities are not the only ones with both “emergency” and “urgent care” on their signs. Such branding can sometimes confuse patients.
While Intuitive’s hybrid facilities offer some price transparency, providers have the upper hand on cost, said Vivian Ho, a health economist at Rice University in Texas. “Patients are at the mercy of what the hospital tells them,” she said.
But Daniel Marthey, an assistant professor of health policy and management at Texas A&M University, said the facilities can help patients find a lower-cost option for care by avoiding steep ER bills when they need only urgent-level care. “This is a potentially good thing for patients,” he said.
Marthey said hospitals may be investing in hybrid facilities to make up for lost revenue after federal surprise medical billing protections took effect in 2022 and restricted what hospitals could charge patients treated by out-of-network providers, particularly in emergencies.
“Basically, they are just competing for market share,” Marthey said.
UF Health has placed its new facilities in suburban areas near freestanding ERs owned by competitors HCA Healthcare and Ascension rather than near its downtown hospital in Jacksonville. It is also building a fourth facility, near The Villages, a large retirement community more than 100 miles south.
“This has been more of an offensive move to expand our market reach and go into suburban markets,” Wylie said.
Though the three centers are not state-approved to care for trauma patients, doctors there said they can handle almost any emergency, including heart attacks and strokes. Patients needing hospitalization are taken by ambulance to the UF hospital about 20 minutes away. If they need to follow up with a specialist, they’re referred to a UF physician.
“If you fall and sprain your leg and need an X-ray and crutches, you can come here and get charged urgent care,” said Justin Nippert, medical director of two of UF’s combo centers. “But if you break your ankle and need it put back in place it can get treated here, too. It’s a one-stop shop.”
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By: Phil Galewitz, KFF Health News
Title: Urgent Care or ER? With ‘One-Stop Shop,’ Hospitals Offer Both Under Same Roof
Sourced From: kffhealthnews.org/news/article/urgent-emergency-care-combo-centers-intuitive-health-jacksonville-florida/
Published Date: Fri, 02 Aug 2024 09:00:00 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/since-fall-of-roe-self-managed-abortions-have-increased/
Kaiser Health News
Since Fall of ‘Roe,’ Self-Managed Abortions Have Increased
Sarah Varney, KFF Health News
Fri, 02 Aug 2024 09:00:00 +0000
The percentage of people who say they’ve tried to end a pregnancy without medical assistance increased after the Supreme Court overturned Roe v. Wade. That’s according to a study published Tuesday in the online journal JAMA Network Open.
Tia Freeman, a reproductive health organizer, leads workshops for Tennesseans on how to safely take medication abortion pills outside of medical settings.
Abortion is almost entirely illegal in Tennessee. Freeman, who lives near Nashville, said people planning to stop pregnancies have all sorts of reasons for wanting to do so without help from the formal health care system — including the cost of traveling to another state, challenge of finding child care, and fear of lost wages.
“Some people, it’s that they don’t have the support networks in their families where they would need to have someone drive them to a clinic and then sit with them,” said Freeman, who works for Self-Managed Abortion; Safe and Supported, a U.S.-based project of Women Help Women, an international nonprofit that advocates for abortion access.
“Maybe their family is superconservative and they would rather get the pills in their home and do it by themselves,” she said.
The new study is from Advancing New Standards in Reproductive Health, a research group based at the University of California-San Francisco. The researchers surveyed more than 7,000 people ages 15 to 49 from December 2021 to January 2022 and another 7,000-plus from June 2023 to July 2023.
Of the respondents who had attempted self-managed abortions, they found the percentage who used the abortion pill mifepristone was 11 in 2023 — up from 6.6 before the Supreme Court ended federal abortion rights in 2022.
One of the most common reasons for seeking a self-administered abortion was privacy concerns, said a study co-author, epidemiologist Lauren Ralph.
“So not wanting others to know that they were seeking or in need of an abortion or wanted to maintain autonomy in the decision,” Ralph said. “They liked it was something under their control that they could do on their own.”
Kristi Hamrick, vice president of media and policy at Students for Life Action, a national anti-abortion group, said she doesn’t believe the study findings, which she said benefit people who provide abortion pills.
“It should surprise no one that the abortion lobby reports their business is doing well, without problems,” Hamrick said in an emailed statement.
Ralph said in addition to privacy concerns, state laws criminalizing abortion also weighed heavily on women’s minds.
“We found 6% of people said the reason they self-managed was because abortion was illegal where they lived,” Ralph said.
In the JAMA study, women who self-managed abortion attempts reported using a range of methods, including using drugs or alcohol, lifting heavy objects, and taking a hot bath. In addition, about 22% reported hitting themselves in the stomach. Nearly 4% reported inserting an object in their body.
The term “self-managed abortion” may conjure images of back-alley procedures from the 1950s and ’60s. But OB-GYN Laura Laursen, a family planning physician in Chicago, said self-managed abortions using medication abortion — the drugs mifepristone and misoprostol — are far safer, whether done inside or outside the health care system.
“They’re equally safe no matter which way you do it,” Laursen said. “It involves passing a pregnancy and bleeding, which is what happens when you have a miscarriage. If your body doesn’t have a miscarriage on its own, these are actually the medications we give women to pass the miscarriage.”
Since Roe‘s end, more than 20 states have banned or further restricted abortion.
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By: Sarah Varney, KFF Health News
Title: Since Fall of ‘Roe,’ Self-Managed Abortions Have Increased
Sourced From: kffhealthnews.org/news/article/self-managed-abortions-increase-post-roe-dobbs-privacy-concerns/
Published Date: Fri, 02 Aug 2024 09:00:00 +0000
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