Kaiser Health News

An Arm and a Leg: How a Surprise Bill Can Hitch a Ride to the Hospital

Published

9 months ago

August 17, 2023

by Dan Weissmann
Wed, 16 Aug 2023 09:00:00 +0000

How did three siblings who took identical ambulance rides (from the same car wreck to the same hospital) end up with three wildly different bills? The answer lies in the No Surprises Act.

That law has protected patients from some of the most outrageous out-of-network medical bills since it took effect in 2022 — except when it comes to ground ambulances. Host Dan Weissmann and producer Emily Pisacreta unpack the story with Bram Sable-Smith of KFF Health News and PIRG's Patricia Kelmar and share what to do if you get hit with an out-of-network ambulance bill.

Dan Weissmann

@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

Credits

Emily Pisacreta
Producer

Adam Raymonda
Audio Wizard

Ellen Weiss
Editor

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Transcript: How a Surprise Bill Can Hitch a Ride to the Hospital

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there —

I have been following the world of medical bills for more than four years now — which makes me still a newbie, really. And here's one thing that's surprised me — beyond how much there is to know, and how deep the problems go.

It's this: Sometimes, some things do actually change for the better.

Like, when I started, one of the most outrageous problems was something called “surprise bills”:

That's when you go someplace, like a hospital, that takes your insurance, and then, SURPRISE! You get a bill from somebody there who says they DON'T take your insurance, and they feel free to charge you ANY ridiculous amount they want, and your insurance may cover a LITTLE of it, or none of it.

I was like, “I will be making episodes about this outrage for a long time.”

Except, at the end of 2020, about two years in for me, Congress actually did something about this outrage. They passed a law called the No Surprises Act.

It said, if you went somewhere in network — someplace your insurance covers — then any bill you get from anybody there? You should be covered as if they were in network. So, they don't take your insurance? Not your problem. They've gotta work something out with your insurer. And if they can't, an arbitrator steps in.

The law went into effect at the beginning of 2022. And: Surprise! In a lot of ways, it's working. One study shows that it's preventing a million of these surprise bills every month. A million. Every month.

Except, of course, nothing's perfect. There are a lot of nuances we could look into, but one thing really stands out: There's actually a hole written into the law that you could drive an ambulance through.

We're gonna look at how that hole got there, what it means, and what MAYBE could get done about it.

This is “An Arm and a Leg,” a show about why health care costs so freaking much and what we can maybe do about it. I'm Dan Weissmann. I'm a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering and useful.

And today we're talking about ambulances. With help from producer Emily Pisacreta.

Emily: Wee-oo-wee-oo

Dan: Haha! Emily you have spent the last few weeks looking at this whole deal

with ambulances. Why don't you take it away?

Emily: Here's a story that illustrates how weird ambulance bills can be. It's a totally wild installment of “Bill of the Month,” the series from NPR and our co-producers KFF Health News.

I talked to the KFF reporter who did the story, Bram Sable-Smith, a Midwest correspondent there.

Bram Sable-Smith: I kind of focus on issues that face consumers, people who are living their lives.

Emily: One person who was just living her life was a woman named Peggy.

Bram Sable-Smith: She's 55 years old. She works in a fine jewelry store in the Chicago suburbs. And her two siblings, Jim and Cynthia, were coming to visit her.

Emily: So Peggy and her siblings are in the car. They're driving out into the country, going to see some horses. They're out on this country road, they come up to an intersection, and all of sudden, bam, the car gets hit by a truck.

Bram Sable-Smith: It spun around and slammed into an electrical box right there on the side of the highway.

Emily: They survive, but they do get pretty banged up. Someone calls 911, and ambulances arrive. And here's where the story goes from being scary to kinda weird. Peggy and her brother and sister need to go to the hospital.

But because an ambulance is not a bus, with seats for everyone, each sibling needs their own ambulance, and: Each of those ambulances is run by a different ambulance service. They end up at the same hospital, they get billed for the exact same services.

Bram: They were all charged for a life support fee and they were all charged a mileage fee.

Emily: However …

Bram: Months later when the bills came for the three of them, they got billed

three very different amounts for the exact same services.

Emily: And the bills were all out of network, and all pretty substantial. Especially Peggy's. Cynthia's bill was $1,250, Jim's $1,415, and poor Peggy? Who invited her siblings on this ill-fated drive?

Bram Sable-Smith: Peggy's bill was for $3,606.

Emily: That's almost three times what her sister got charged. And these are all heavy-duty bills. Higher than what research shows is the average out-of-network ambulance bill.

But the fact that they're out of network, like not billed to their insurance? That's not an outlier. It's estimated that 71% of ambulance bills are out of network on commercial plans. Which means 71% of the time …

Bram Sable-Smith: … ambulances are essentially able to charge whatever they want.

Emily: Result? These random ass charges.

Dan: Hold up. So this is exactly the kind of thing the No Surprises Act was supposed to prevent: out-of-network bills from someone you didn't pick yourself. You know, like an ambulance. And you're saying ambulances are especially unlikely to be covered by your insurance. But they're not governed by the No Surprises Act.

Emily: That's right.

Dan: OK, so why did Congress leave ambulances out of the No Surprises Act?

Emily: I mean, I had the same question. It's like … Congress was able to juggle all the demands of the insurance lobby and health care providers including, I should mention, AIR ambulance companies

Dan: Wait, that's helicopter rides?

Emily: Yep. Helicopters, air ambulances, that were charging tens of thousands of dollars a ride. Congress dealt with them here, but, like … not regular degular ambulances? So yeah, why not?

And the answer has to do with who actually runs ambulances in the U.S. And how they get their funding.

That story starts decades ago. You ready for this?

Dan: What, a ride in the Wayback Machine? Yeah, I mean have you met me? I was born ready for this.

Emily: OK, sea tbelts on. Once upon a time, about 60 years ago …

Patricia Kelmar: We really didn't have an emergency transportation system for

medical care in the U.S.

Emily: That's Patricia Kelmar. She runs health care campaigns at a consumer-advocacy organization called the Public Interest Research Group. She lobbied for the No Surprises Act. And when we talked, we got into the history of ambulances, because everything has an origin story. She says a national ambulance system started with a big federal report in 1966. And here's what it said:

Patricia Kelmar: We were losing a lot of people who were having medical emergencies at home or out in the community and didn't get to the hospital fast enough.

Emily: The report identified accidental injuries as the leading cause of death for Americans in the first half of their life span. It said more Americans died from motor vehicle accidents in 1965 than American troops in the Korean War.

Patricia Kelmar: So this report really opened the eyes of public health officials, and there was a movement in the early Seventies to create a national emergency transportation system.

Dan: Wait! This reminds me of a show that was on when I was a kid called Emergency! with an exclamation point.

Emily: Yeah totally!

[Emergency! theme]

[Clip from Emergency! plays]

Dispatcher: Rampart Emergency?

Paramedic 1: Rampart, this is Squad 51.

Dan: Yeah! Kids I knew had Emergency! lunchboxes

Emily: Yeah, it was a whole cultural moment. It seems like this apparently had American audiences on the edge of their seats.

[Clip from Emergency! plays]

Dispatcher: Go ahead, 51.

Paramedic 1: Rampart, we have a male patient here, age 17. He has, uh, acute abdominal pain.

Emily: That first aired in 1972.

[Clip from Emergency! plays]

Paramedic 1: Patient's, uh, ingested two loaves of raw dough. Ambulance has just arrived.

[Emergency! Sound]

Emily: Lawmakers had a vision to match. In 1973, Congress passed the Emergency Medical Services Systems Act, to bring high-quality emergency care to every part of the country.

Patricia Kelmar: It was developed thinking about regions so that we didn't have too many ambulances, but we had enough ambulances to serve different populations, and the best part was there was federal funding to make this happen.

Emily: But then in the '80s … the structure of that funding changed. Now states would get block grants, big chunks of federal health care dollars that they would decide for themselves how to use.

Patricia Kelmar: And so every community then, throughout our country, responded to this change in the funding system by … understanding that we still need ambulances, but funding it in different ways.

Emily: Which is why in some places you'd never get a bill for an ambulance. The local city or county governments owns and operates it, and a mix of funding streams, including local taxes just cover it.

And in other places, you certainly would get a bill. And it wouldn't be from the county, but it'd be from a hospital, or a for-profit EMS company. Because they run about 40% of this landscape too, and some of those companies are even owned by private equity.

And still in other places, you get volunteer ambulance companies running bake sales or even raising money on GoFundMe.

In the case of Peggy and her siblings, just by virtue of where they got into the accident, they ended up in publicly run ambulances from three different jurisdictions, each with their own funky funding, each with their own unique pricing scheme.

Dan: Huh. So that's where things stood with ambulances when Congress was cooking up the No Surprises Act. Coming right up: Why did that lead Congress to punt? And what might come next?

[midroll]

Dan: This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That's a nonprofit newsroom covering health care in America. Their work is absolutely terrific; I love partnering with them. We'll have a little more information about KFF Health News at the end of this episode.

[midroll music fades out]

Dan: OK … So, since the 1960s, we've got ambulance care around the country that meets certain standards — great. But how the ambulances get funded, who owns them, and how much you get billed after it drops you off, all these things depend on location — not so great.

But, you know: hospital funding, hospital bills … that's not standard across the country, either. Why did Congress apply the No Surprises Act to hospitals, but not ambulance rides? Emily, looking at you here.

Emily: Hey, look, even experts have a tough time with that one. Here's an economist named Loren Adler from the Brookings Institution. He researches health insurance and he watched the whole No Surprises Act take shape.

I asked him: So, no ambulances. Why's that?

Loren Adler: So, I'm not sure I can give you a super satisfactory answer. I don't really think there's a great reason. Uh, I can give the sort …

Emily: You don't have to … you certainly don't have to defend …

Loren Adler: Yeah, um, that's true.

Emily: Actually he did have a couple of reasons. He started with: who actually runs ambulance services most of the time.

Loren Adler: About 60% of emergency ground ambulance transport is actually billed by local governments or fire departments.

Dan: So “Big Ambulance Incorporated” didn't steamroll Congress?

Emily: Not according to Loren.

Loren Adler: As much as observers might think that lobbyists and sort of stakeholder industry have a lot of say over Congress, I'm not objecting to that characterization. Uh, you know, calls from local lawmakers and mayors and fire department chiefs have even more weight.

Dan: So, OK. We're talking local public servants. Like, Leslie Knope from Parks and Rec, if she were a fire chief.

Emily: Yeah, and as Loren might say: A high ambulance bill looks like an outrage to you, but to her it looks like something else.

Loren Adler: It is effectively a source of local government revenue.

Dan: So Congress was hearing from Leslie Knope, “Are you trying to bankrupt

my little town of Pawnee?” And they were like, “OK. So, no ambulances then.”

Emily: Right. Loren also sees a much nerdier factor at play.

Dan: Hit me.

Emily: Remember, whether it's Leslie Knope or “Big Ambulance Inc.” running them, local ambulance services are overwhelmingly out of network.

And so according to Loren, the mechanisms that make the No Surprises Act work would be hard to apply.

Loren Adler: The sort of structure of the No Surprises Act is all kind of based around this median in-network price,

Emily: Did you catch that? Median in-network price.

That is, Congress had to decide: If we're gonna make a law where an out-of-network provider can't just charge Whatever They Want anymore in these situations, then … what are they supposed to get paid? Congress said …

Loren: We're gonna tell insurers you have to pay whatever your sort of average in-network price was for the service.

Emily: But with so few in-network providers, there is no reliable, average in-network price.

Dan: OK. That was super-nerdy. And I'm gonna note that even if Leslie Knope and a bunch of nerds led the charge here, Big Ambulance Inc. got the benefit too. So what now?

Emily: Well, Congress did recognize that they were leaving this giant sign up at the door that said “Welcome Surprise Ambulance Bills.” And they said, OK, we can't figure this shit out now. But let's have a bunch of experts get together and let's have them write us some recommendations for later. They told the Department of Health and Human Services: Go form a committee.

And now Loren is on that committee. So is Patricia Kelmar — the consumer advocate we heard from earlier.

Patricia Kelmar: The advisory committee is called the Ground Ambulance and Patient Billing Advisory Committee. If that's not a mouthful, I don't know …

Emily: Yeah. Yep.

Patricia Kelmar: But it's, it's probably indicative of how complicated finding solutions to surprise billing can be.

Emily: Patricia and the panel, they first met in early May, and the law says they have 180 days after that to come up with some policy recommendations for lawmakers to take under advisement. After that, it'll be up to Congress to take action again.

Dan: And, I mean, not to be a cynic, but it took years to get the No Surprises Act passed. What if I decide not to hold my breath until Congress does something about ambulances?

Emily: You'll be forgiven, my dude.

Dan: So, where does that leave us? Scrounging for in-the-meantime advice, right?

Emily: Yep. Patricia has some tips.

Patricia Kelmar: The first thing we recommend is that you talk to both your insurer and the ambulance company and try to negotiate better coverage or lowering of the bill.

Emily: If you get your insurance through work, your HR department may be able to help. Let them know what happened and see whether they can get insurance to pay it off.

If that's not an option, try to negotiate with the ambulance provider.

Patricia Kelmar: Always explain your financial situation. Try to work out something. I have. Patients who called me about their ambulance bills, and when they call and explain, sometimes they get a discount.

Emily: And finally, there might actually be state local laws in your area that pertain to balance bills, that include ambulances.

Dan: Ooh, I've got one more tip!

Emily: Mmmhm?

Dan: This one is from our pal Jared Walker. He runs a group called Dollar For. Their whole thing is helping people get financial assistance, or charity care. ‘Cause, you know, nonprofit hospitals are required to give price breaks to at least SOME people with low incomes.

And Jared says: Ambulance companies aren't required to have those kinds of policies, but A LOT OF THEM DO.

He also says: You should look them up. Like, the specific policy for whatever company you are dealing with. Because these policies can have funny names … like “Compassionate Care Policy.” And if you don't ask for them by name, the person you call may pretend they don't know what you're talking about. That's what Jared says. So, Jared, if you're listening, big thanks to you for those crucial details.

Emily: Cool cool cool. But none of these solutions work for everyone.

Peggy, the woman who got into an accident with her siblings? Her bill went to collections, and she had a hell of a time fighting back. The bill disappeared only after her story aired on national radio.

Dan: That one's definitely not gonna work for everybody.

Emily: No. Which reminds me of another thing Patricia told me.

Patricia: For the ambulance committee, there's a public portion. People can log in, they can listen, people can share their stories, tell us something about what they want us to do, and if they don't get called on that time, they can just write a note, and let us know.

Dan: Wherever you're listening to this, we'll post information about how you can chime in.

Also, I found a list of 10 states that have surprise-billing protections for ambulances — including Illinois, Ohio, New York, Colorado. We'll have a link to the list of all 10 states as well.

Emily, thank you so much for telling us all about ambulances.

Emily: My pleasure.

Dan: And I've got a request here. Something I could use everybody's help with:

We are planning an upcoming episode about AI. ‘Cause we're wondering: Can we train ChatGPT to make it easier to appeal stupid insurance denials?

And we're gonna need … some raw material. Some stupid insurance denials.

If you've gotten one recently, and you'd like some help from a chatbot — and an actual human expert that we will recruit — can you please get in touch? Go to armandalegshow.com/contact.

Let us know the story. Please include the relevant documents. We won't share your personal information without your OK, but if we use your story, we will want to talk with you, maybe put your voice on the show.

Are you game? Or: Do you know somebody who might be? Let's get our new robot overlords working for us, you know, while we can.

And besides: I'm pretty sure the folks at the insurance companies are already trying to do the same. Let's start catching up.

Again: The place to share is: armandalegshow.com/contact.. Thank you so much. This should be fun.

We'll have another episode for you in a few weeks.

Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta — with help from Lucy Little, Bella Cjazkowski, and me, Dan Weissmann — and edited by Ellen Weiss.

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager.

“An Arm and a Leg” is produced in partnership with KFF Health News — formerly known as Kaiser Health News.

That's a national newsroom producing in-depth journalism about health care in America, and a core program at KFF — an independent source of health policy research, polling, and journalism.

And yes, you did hear the name Kaiser in there, and no: KFF isn't affiliated with the health care giant Kaiser Permanente. You can learn more about KFF Health News at armandalegshow.com/KFF.

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

Thanks to Public Narrative — that's a Chicago-based group that helps journalists and nonprofits tell better stories — for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at www.publicnarrative.org.

And thanks to everybody who supports this show financially.

If you haven't yet, we'd love for you to join us. The place for that is armandalegshow.com/support.

Thank you!

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you've got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

By: Dan Weissmann
Title: An Arm and a Leg: How a Surprise Bill Can Hitch a Ride to the Hospital
Sourced From: kffhealthnews.org/news/podcast/how-a-surprise-bill-can-hitch-a-ride-to-the-hospital/
Published Date: Wed, 16 Aug 2023 09:00:00 +0000

Post Views: 367

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Newsom Boosted California’s Public Health Budget During Covid. Now He Wants To Cut It.

Published

13 hours ago

May 20, 2024

Staff Editor

Angela Hart
Mon, 20 May 2024 09:00:00 +0000

When a doctor in Pasadena, California, reported in October that a hospital patient was exhibiting classic symptoms of dengue fever, such as vomiting, a rash, and bone and joint pain, local disease investigators snapped into action.

The mosquito-borne virus is common in places like Southeast Asia, East Africa, and Latin America, and when Americans contract the disease it is usually while traveling. But in this case, the patient hadn't left California.

Epidemiologists and public health nurses visited 175 households to conduct blood draws and local pest control workers began fumigating the patient's neighborhood. In the process, they discovered a second infected person who hadn't traveled.

Both patients recovered, and in that neighborhood nearly 65% of the carrier mosquitoes, part of a genus called Aedes, were eradicated within seven days, said Matthew Feaster, an epidemiologist with the Pasadena Public Health Department.

The swift and intensive response was funded largely by a new bucket of money in the state budget for public health and preparedness across California, said Manuel Carmona, Pasadena's deputy director of public health.

In the midst of the covid-19 pandemic, and facing pleas from public health officials who said they didn't have enough resources to track and contain the disease, California Gov. Gavin Newsom had agreed to allocate $300 million each year for the state's chronically underfunded public health system.

Two years after the money started to flow, and facing a $45 billion deficit, the second-term Democratic governor proposes to slash the funding entirely.

“This is a huge step backwards,” said Kat DeBurgh, executive director of the Health Officers Association of California. “We can't go back to where we were before the pandemic. That future looks very scary.”

Michelle Gibbons, executive director of the County Health Executives Association of California, said about 900 public health workers have already been hired with the new funding — including some of Pasadena's disease investigators — positions that are at risk should Newsom prevail.

The governor unveiled his updated budget plan for the 2024-25 fiscal year on May 10, saying it pained him to push such deep cuts to health and human services but that the state needed to make “difficult decisions” to balance its budget. Unlike the federal government, it cannot operate on a deficit.

Tense budget negotiations are underway between Newsom and the leaders of the state Senate and Assembly, who must reach an agreement on the state's estimated $288 billion budget by June 15.

“We have a shortfall. We have to be sober about the reality, what our priorities are,” Newsom said after unveiling his suggested cuts. “This is a program that we wish we could continue to absorb and afford.”

Public health officials lobbied Newsom hard in 2020 and 2021 to get more resources, and secured additional annual funding of $100 million for the state Department of Public Health and $200 million for the 61 local health departments that form the backbone of California's public health system.

Now they are fighting to preserve their funding — just as cities and counties had begun using it to bolster California's public health defenses.

Some of the workers hired with the money are battling homelessness, fighting climate change, or surveying farmworkers to identify their health and social needs, but most are communicable disease specialists such as epidemiologists and public health nurses charged with investigating threats and outbreaks.

Measles infections are breaking out in Davis, San Diego, Humboldt County, and elsewhere. Long Beach declared a public health emergency early this month over an outbreak of tuberculosis, which spreads through the air when an infected person coughs, speaks, or sneezes. Los Angeles public health authorities are investigating a spate of hepatitis A infections among homeless people.

And around the United States, the spread of bird flu from animals to humans is causing widespread concern.

“The more time this virus is out there transferring between cows and birds, the more chance it has to evolve and spread human to human,” DeBurgh said. She argues that public health agencies must have enough funding to hire workers who can halt threats as they emerge — like they did in Pasadena.

“That dengue outbreak was stopped because we had more ability to hire, and that was a huge public health success,” she said.

Pasadena public health authorities teamed up with the local mosquito control agency to spray pesticides and deployed 29 staffers to test residents for dengue.

“We put our best people on that case,” Carmona said, adding that four of the disease investigators were funded with about $1 million in new state money the department receives each year. “Without it, we wouldn't have a timely response and we probably would have identified dengue as West Nile or some other type of viral virus.”

Rob Oldham, the interim public health officer and director of Health and Human Services for Placer County, said he's weighing the “devastating” cuts he'd have to make if Newsom's proposal passes. The county has hired 11 full-time and six part-time workers using about $1.8 million in new annual state funding, he said.

“This money was just starting to take hold,” he said. “Honestly, we're scrambling, just as we're responding to another measles case.”

Legislative leaders were reluctant to say whether they would try to safeguard the funding, as they face deep cuts in nearly every sector of state government, including early childhood education, public safety, energy, and transportation.

“We're knee-deep in budget negotiations but we're working like hell to protect the progress we've made,” said state Senate leader Mike McGuire, a Northern California Democrat.

Public health officials warned the state would be vulnerable to health and economic disasters should they lose the hard-won funding.

“It's tempting to go back to what we had before, because when we do our jobs, we are invisible. Crises are averted,” Gibbons said. “But it's devastating to think of going back to this boom-and-bust cycle of public health funding that goes neglect, panic, repeat.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

——————————
By: Angela Hart
Title: Newsom Boosted California's Public Health Budget During Covid. Now He Wants To Cut It.
Sourced From: kffhealthnews.org/news/article/gavin-newsom-california-public-health-budget-cuts/
Published Date: Mon, 20 May 2024 09:00:00 +0000

Post Views: 62

Kaiser Health News

Medicaid Unwinding Deals Blow to Tenuous System of Care for Native Americans

Published

15 hours ago

May 20, 2024

Staff Editor

Jazmin Orozco Rodriguez
Mon, 20 May 2024 09:00:00 +0000

About a year into the process of redetermining Medicaid eligibility after the covid-19 public health emergency, more than 20 million people have been kicked off the joint federal-state program for low-income families.

A chorus of stories recount the ways the unwinding has upended people's lives, but Native Americans are proving particularly vulnerable to losing coverage and face greater obstacles to reenrolling in Medicaid or finding other coverage.

“From my perspective, it did not work how it should,” said Kristin Melli, a pediatric nurse practitioner in rural Kalispell, Montana, who also provides telehealth services to tribal members on the Fort Peck Reservation.

The redetermination process has compounded long-existing problems people on the reservation face when seeking care, she said. She saw several patients who were still eligible for benefits disenrolled. And a rise in uninsured tribal members undercuts their health systems, threatening the already tenuous access to care in Native communities.

One teenager, Melli recalled, lost coverage while seeking lifesaving care. Routine lab work raised flags, and in follow-ups Melli discovered the girl had a condition that could have killed her if untreated. Melli did not disclose details, to protect the patient's privacy.

Melli said she spent weeks working with tribal nurses to coordinate lab monitoring and consultations with specialists for her patient. It wasn't until the teen went to a specialist that Melli received a call saying she had been dropped from Medicaid coverage.

The girl's parents told Melli they had reapplied to Medicaid a month earlier but hadn't heard back. Melli's patient eventually got the medication she needed with help from a pharmacist. The unwinding presented an unnecessary and burdensome obstacle to care.

Pat Flowers, Montana Democratic Senate minority leader, said during a political event in early April that 13,000 tribal members had been disenrolled in the state.

Native American and Alaska Native adults are enrolled in Medicaid at higher rates than their white counterparts, yet some tribal leaders still didn't know exactly how many of their members had been disenrolled as of a survey conducted in February and March. The Tribal Self-Governance Advisory Committee of the Indian Health Service conducted and published the survey. Respondents included tribal leaders from Alaska, Arizona, Idaho, Montana, and New Mexico, among other states.

Tribal leaders reported many challenges related to the redetermination, including a lack of timely information provided to tribal members, patients unaware of the process or their disenrollment, long processing times, lack of staffing at the tribal level, lack of communication from their states, concerns with obtaining accurate tribal data, and in cases in which states have shared data, difficulties interpreting it.

Research and policy experts initially feared that vulnerable populations, including rural Indigenous communities and families of color, would experience greater and unique obstacles to renewing their health coverage and would be disproportionately harmed.

“They have a lot at stake and a lot to lose in this process,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and a research professor at the McCourt School of Public Policy. “I fear that that prediction is coming true.”

Cammie DuPuis-Pablo, tribal health communications director for the Confederated Salish and Kootenai Tribes in Montana, said the tribes don't have an exact number of their members disenrolled since the redetermination began, but know some who lost coverage as far back as July still haven't been reenrolled.

The tribes hosted their first outreach event in late April as part of their effort to help members through the process. The health care resource division is meeting people at home, making calls, and planning more events.

The tribes receive a list of members' Medicaid status each month, DuPuis-Pablo said, but a list of those no longer insured by Medicaid would be more helpful.

Because of those data deficits, it's unclear how many tribal members have been disenrolled.

“We are at the mercy of state Medicaid agencies on what they're willing to share,” said Yvonne Myers, consultant on the Affordable Care Act and Medicaid for Citizen Potawatomi Nation Health Services in Oklahoma.

In Alaska, tribal health leaders struck a data-sharing agreement with the state in July but didn't begin receiving information about their members' coverage for about a month — at which point more than 9,500 Alaskans had already been disenrolled for procedural reasons.

“We already lost those people,” said Gennifer Moreau-Johnson, senior policy adviser in the Department of Intergovernmental Affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization. “That's a real impact.”

Because federal regulations don't require states to track or report race and ethnicity data for people they disenroll, fewer than 10 states collect such information. While the data from these states does not show a higher rate of loss of coverage by race, a KFF report states that the data is limited and that a more accurate picture would require more demographic reporting from more states.

Tribal health leaders are concerned that a high number of disenrollments among their members is financially undercutting their health systems and ability to provide care.

“Just because they've fallen off Medicaid doesn't mean we stop serving them,” said Jim Roberts, senior executive liaison in the Department of Intergovernmental Affairs of the Alaska Native Tribal Health Consortium. “It means we're more reliant on other sources of funding to provide that care that are already underresourced.”

Three in 10 Native American and Alaska Native people younger than 65 rely on Medicaid, compared with 15% of their white counterparts. The Indian Health Service is responsible for providing care to approximately 2.6 million of the 9.7 million Native Americans and Alaska Natives in the U.S., but services vary across regions, clinics, and health centers. The agency itself has been chronically underfunded and unable to meet the needs of the population. For fiscal year 2024, Congress approved $6.96 billion for IHS, far less than the $51.4 billion tribal leaders called for.

Because of that historical deficit, tribal health systems lean on Medicaid reimbursement and other third-party payers, like Medicare, the Department of Veterans Affairs, and private insurance, to help fill the gap. Medicaid accounted for two-thirds of third-party IHS revenues as of 2021.

Some tribal health systems receive more federal funding through Medicaid than from IHS, Roberts said.

Tribal health leaders fear diminishing Medicaid dollars will exacerbate the long-standing health disparities — such as lower life expectancy, higher rates of chronic disease, and inferior access to care — that plague Native Americans.

The unwinding has become “all-consuming,” said Monique Martin, vice president of intergovernmental affairs for the Alaska Native Tribal Health Consortium.

“The state's really having that focus be right into the minutiae of administrative tasks, like: How do we send text messages to 7,000 people?” Martin said. “We would much rather be talking about: How do we address social determinants of health?”

Melli said she has stopped hearing of tribal members on the Fort Peck Reservation losing their Medicaid coverage, but she wonders if that means disenrolled people didn't seek help.

“Those are the ones that we really worry about,” she said, “all of these silent cases. … We only know about the ones we actually see.”

——————————
By: Jazmin Orozco Rodriguez
Title: Medicaid Unwinding Deals Blow to Tenuous System of Care for Native Americans
Sourced From: kffhealthnews.org/news/article/medicaid-unwinding-endangers-native-american-health-care/
Published Date: Mon, 20 May 2024 09:00:00 +0000

Post Views: 43

Kaiser Health News

The Lure of Specialty Medicine Pulls Nurse Practitioners From Primary Care

Published

3 days ago

May 17, 2024

Staff Editor

Michelle Andrews
Fri, 17 May 2024 09:00:00 +0000

For many patients, seeing a nurse practitioner has become a routine part of primary care, in which these “NPs” often perform the same tasks that patients have relied on doctors for.

But NPs in specialty care? That's not routine, at least not yet. Increasingly, though, nurse practitioners and physician assistants are joining cardiology, dermatology, and other specialty practices, broadening their skills and increasing their income.

This development worries some people who track the health workforce, because current trends suggest primary care, which has counted on nurse practitioners to backstop physician shortages, soon might not be able to rely on them to the same extent.

“They're succumbing to the same challenges that we have with physicians,” said Atul Grover, executive director of the Research and Action Institute at the Association of American Medical Colleges. The rates NPs can command in a specialty practice “are quite a bit higher” than practice salaries in primary care, he said.

When nurse practitioner programs began to proliferate in the 1970s, “at first it looked great, producing all these nurse practitioners that go to work with primary care physicians,” said Yalda Jabbarpour, director of the American Academy of Family Physicians' Robert Graham Center for Policy Studies. “But now only 30% are going into primary care.”

Jabbarpour was referring to the 2024 primary care scorecard by the Milbank Memorial Fund, which found that from 2016 to 2021 the proportion of nurse practitioners who worked in primary care practices hovered between 32% and 34%, even though their numbers grew rapidly. The proportion of physician assistants, also known as physician associates, in primary care ranged from 27% to 30%, the study found.

Both nurse practitioners and physician assistants are advanced practice clinicians who, in addition to graduate degrees, must complete distinct education, training, and certification steps. NPs can practice without a doctor's supervision in more than two dozen states, while PAs have similar independence in only a handful of states.

About 88% of nurse practitioners are certified in an area of primary care, according to the American Association of Nurse Practitioners. But it is difficult to track exactly how many work in primary care or in specialty practices. Unlike physicians, they're generally not required to be endorsed by a national standard-setting body to practice in specialties like oncology or cardiology, for example. The AANP declined to answer questions about its annual workforce survey or the extent to which primary care NPs are moving toward specialties.

Though data tracking the change is sparse, specialty practices are adding these advanced practice clinicians at almost the same rate as primary care practices, according to frequently cited research published in 2018.

The clearest evidence of the shift: From 2008 to 2016, there was a 22% increase in the number of specialty practices that employed nurse practitioners and physician assistants, according to that study. The increase in the number of primary care practices that employed these professionals was 24%.

Once more, the most recent projections by the Association of American Medical Colleges predict a dearth of at least 20,200 primary care physicians by 2036. There will also be a shortfall of non-primary care specialists, including a deficiency of at least 10,100 surgical physicians and up to 25,000 physicians in other specialties.

When it comes to the actual work performed, the lines between primary and specialty care are often blurred, said Candice Chen, associate professor of health policy and management at George Washington University.

“You might be a nurse practitioner working in a gastroenterology clinic or cardiology clinic, but the scope of what you do is starting to overlap with primary care,” she said.

Nurse practitioners' salaries vary widely by location, type of facility, and experience. Still, according to data from health care recruiter AMN Healthcare Physician Solutions, formerly known as Merritt Hawkins, the total annual average starting compensation, including signing bonus, for nurse practitioners and physician assistants in specialty practice was $172,544 in the year that ended March 31, slightly higher than the $166,544 for those in primary care.

According to forecasts from the federal Bureau of Labor Statistics, nurse practitioner jobs will increase faster than jobs in almost any other occupation in the decade leading up to 2032, growing by 123,600 jobs or 45%. (Wind turbine service technician is the only other occupation projected to grow as fast.) The growth rate for physician assistants is also much faster than average, at 27%. There are more than twice as many nurse practitioners as physician assistants, however: 323,900 versus 148,000, in 2022.

To Grover, of the AAMC, numbers like this signal that there will probably be enough NPs, PAs, and physicians to meet primary care needs. At the same time, “expect more NPs and PAs to also flow out into other specialties,” he said.

When Pamela Ograbisz started working as a registered nurse 27 years ago, she worked in a cardiothoracic intensive care unit. After she became a family nurse practitioner a few years later, she found a job with a similar specialty practice, which trained her to take on a bigger role, first running their outpatient clinic, then working on the floor, and later in the intensive care unit.

If nurse practitioners want to specialize, often “the doctors mentor them just like they would with a physician residency,” said Ograbisz, now vice president of clinical operations at temporary placement recruiter LocumTenens.com.

If physician assistants want to specialize, they also can do so through mentoring, or they can receive “certificates of added qualifications” in 10 specialties to demonstrate their expertise. Most employers don't “encourage or require” these certificates, however, said Jennifer Orozco, chief medical officer at the American Academy of Physician Associates.

There are a number of training programs for family nurse practitioners who want to develop skills in other areas.

Raina Hoebelheinrich, 40, a family nurse practitioner at a regional medical center in Yankton, South Dakota, recently enrolled in a three-semester post-master's endocrinology training program at Mount Marty University. She lives on a farm in nearby northeastern Nebraska with her husband and five sons.

Hoebelheinrich's new skills could be helpful in her current hospital job, in which she sees a lot of patients with acute diabetes, or in a clinic setting like the one in Sioux Falls, South Dakota, where she is doing her clinical endocrinology training.

Lack of access to endocrinology care in rural areas is a real problem, and many people may travel hundreds of miles to see a specialist.

“There aren't a lot of options,” she said.

——————————
By: Michelle Andrews
Title: The Lure of Specialty Medicine Pulls Nurse Practitioners From Primary Care
Sourced From: kffhealthnews.org/news/article/nurse-practitioners-trend-primary-care-specialties/
Published Date: Fri, 17 May 2024 09:00:00 +0000

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